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As doctors hand off patients, miscommunication at sign-outs can cause errors

Yale Medicine Magazine, 2009 - Winter


“Sign-out,” the conversation at shift change when hospital patients’ information is handed off from one team of doctors to another, is the delicate hinge on which much medical communication turns. But this commonplace event can be fraught with miscommunications that frustrate doctors and pose a hazard to patients.

That’s because doctors don’t have a standard approach for sign-out—unlike those for the formal history and physical presentation—nor are they supervised when first doing it. “We have no training at all; there’s nothing,” said Leora I. Horwitz, M.D., assistant professor of medicine. Instead, residents wing it: they might painstakingly explain the team’s reasoning for each patient’s plan of care—or they might simply read names and diagnoses to a colleague and append a few comments to the list.

Because much of what is known about sign-out is anecdotal, Horwitz decided to study the practice. She and her team studied eight teams’ handoffs over 12 days, audiotaping evening sign-outs and collecting doctors’ printouts, then asking the covering team in the morning if there had been any sign-out-related problems overnight.

There certainly had been. In 88 sign-out sessions, 24 sign-out-related problems came up. Fifteen related to inefficient care—the covering team had to duplicate work or research—but there were five episodes of delayed diagnosis or care and four close calls. In one case of miscommunication, a patient was transferred to intensive care in part because the covering team had not been warned about her bronchospasm.

These results, published in the September 8 Archives of Internal Medicine, will surprise few physicians who have had to start from scratch while caring for a colleague’s patients. But with reductions in residents’ work hours, a rising hospital census and a national impetus to reduce medical errors, sloppiness at sign-out is evolving from nuisance to pressing concern.

How should clinicians sign out? They might start by looking outside medicine. Other groups involved in high-risk or error-prone work, including the nuclear power, automotive and airline industries, have developed effective methods of handoff. “They teach it, they train it, they concentrate on it—which we don’t do,” Horwitz said. “What you want to hand off in person or on paper is the higher-order stuff, the clinical reasoning part, the synthesis, the judgment. Handoff is about understanding.”

Based on these results, the internal medicine department began a sign-out curriculum for residents that is now in its third year. Horwitz often teaches it, and she has also developed sign-out templates for hospital residents in other specialties. She plans next to study sign-out during hospital discharge.

“We just haven’t thought about [sign-out] as part of our job,” she said. “We don’t prioritize this as a safety issue, and that’s part of what [our team is] trying to change by pointing out what goes wrong.”