Time to sign off on signout.

Daniel M Stein; Peter D Stetson

Commentary

Time to sign off on signout.

July 20, 2011

Stein DM, Stetson PD. Acad Med. 2011;86(7):804-6.

View more articles from the same authors.

This commentary suggests standardized sign-outs can improve communication and handoffs.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Policy and the future of adverse event detection using information technology.

March 6, 2005

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

July 11, 2012

In search of common ground in handoff documentation in an intensive care unit.

May 23, 2012

Registration-associated patient misidentification in an academic medical center: causes and corrections.

January 10, 2007

Hospital- and system-wide interventions for health care-associated infections: a systematic review.

September 16, 2020

Estimating hospital-related deaths due to medical error: a perspective from patient advocates.

February 22, 2017

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

September 6, 2023

Association between treatment by locum tenens internal medicine physicians and 30-day mortality among hospitalized Medicare beneficiaries.

December 20, 2017

Who gets the benefit of the doubt? Performance evaluations, medical errors, and the production of gender inequality in emergency medical education.

March 18, 2020

Quality gaps identified through mortality review.

February 1, 2017

Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units.

September 23, 2020

The patient died: what about involvement in the investigation process?

June 24, 2020

Using root cause analysis to reduce falls with injury in the psychiatric unit.

March 21, 2012

Using root cause analysis to reduce falls with injury in community settings.

August 1, 2012

Suicide attempts and completions on medical-surgical and intensive care units.

January 29, 2014

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

May 3, 2023

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy.

January 12, 2022

Diagnostic accuracy of pediatric teledermatology using parent-submitted photographs: a randomized clinical trial.

November 29, 2017

Medicare's policy not to pay for treating hospital-acquired conditions: the impact.

September 30, 2009

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

May 28, 2014

Review of alternatives to root cause analysis: developing a robust system for incident report analysis.

September 18, 2019

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

December 8, 2010

A multihospital safety improvement effort and the dissemination of new knowledge.

March 6, 2005

Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls.

May 10, 2017

An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.

November 14, 2018

Root cause analysis of ICU adverse events in the Veterans Health Administration.

August 30, 2017

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards.

June 19, 2013

The Daily Plan: including patients for safety's sake.

April 11, 2012

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

November 17, 2021

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.

March 15, 2006

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

May 24, 2023

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement.

August 17, 2011

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

Systemic vulnerabilities to suicide among veterans from the Iraq and Afghanistan conflicts: review of case reports from a national Veterans Affairs database.

April 20, 2011

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program.

September 14, 2011

The effect of facility complexity on perceptions of safety climate in the operating room: size matters.

June 16, 2010

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

Improving the bar-coded medication administration system at the Department of Veterans Affairs.

August 9, 2006

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.

June 21, 2017

Inpatient suicide and suicide attempts in Veterans Affairs hospitals.

August 20, 2008

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review.

August 16, 2023

The Swiss cheese model of adverse event occurrence—closing the holes.

January 13, 2016

Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry.

June 6, 2012

Retained guidewires in the Veterans Health Administration: getting to the root of the problem.

May 9, 2018

Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level.

November 25, 2015

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

March 13, 2013

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training.

November 18, 2009

The application of the Global Trigger Tool: a systematic review.

October 26, 2016

Diagnostic error in the emergency department: learning from national patient safety incident report analysis.

January 15, 2020

How well do incident reporting systems work on inpatient psychiatric units?

September 5, 2018

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

May 27, 2020

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

March 14, 2012

Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.

April 30, 2014

A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals.

February 17, 2010

Awareness and use of a cognitive aid for anesthesiology.

September 19, 2007

Medical team training: applying crew resource management in the Veterans Health Administration.

May 30, 2007

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.

February 13, 2019

Sharing lessons learned to prevent incorrect surgery.

November 21, 2012

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

April 29, 2015

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.

July 19, 2017

Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery.

November 18, 2015

Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit.

May 3, 2006

Curriculum development and implementation of a national interprofessional fellowship in patient safety.

September 5, 2018

CMS changes in reimbursement for HAIs: setting a research agenda.

May 5, 2010

Associations of physicians’ prescribing experience, work hours, and workload with prescription errors.

November 18, 2020

Wrong-side thoracentesis: lessons learned from root cause analysis.

July 2, 2014

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

November 11, 2020

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

October 24, 2018

Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3?

July 21, 2010

Adverse patient safety events during the COVID epidemic.

May 17, 2023

Impact of attending physician workload on patient care: a survey of hospitalists.

February 6, 2013

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Canadian Association of University Surgeons' Annual Symposium. Surgical simulation: the solution to safe training or a promise unfulfilled?

September 5, 2012

Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period.

November 17, 2016

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.

August 23, 2017

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

July 27, 2011

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

August 18, 2010

Incorrect surgical procedures within and outside of the operating room.

November 25, 2009

Promising roles for pharmacists in addressing the U.S. opioid crisis.

February 14, 2018

Root cause analysis of ambulatory adverse drug events that present to the emergency department.

May 7, 2014

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

Association between implementation of a medical team training program and surgical morbidity.

January 4, 2012

Association between implementation of a medical team training program and surgical mortality.

October 20, 2010

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

September 1, 2010

Identifying potential predictors of a safe attending physician workload: a survey of hospitalists.

October 30, 2013

Prescription of long-acting opioids and mortality in patients with chronic noncancer pain.

November 30, 2016

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

August 30, 2017

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

August 25, 2010

Sharing lessons learned to prevent adverse events in anesthesiology nationwide.

August 21, 2019

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.

September 12, 2018

Consumer rankings and health care: toward validation and transparency.

October 12, 2016

Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application.

September 7, 2005

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

April 1, 2020

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Making electronic health records both SAFER and SMARTER.

July 27, 2022

Information concerning ICU patients’ families in the handover—the clinicians’ “game of whispers”: a qualitative study.

October 14, 2020

Hospitals Can Take Key Steps to Improve Safe Use of Digital Systems.

August 12, 2020

Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.

August 5, 2020

WebM&M Cases

Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing

June 24, 2020

Information transfer at hospital discharge: a systematic review.

April 15, 2020

How common mental shortcuts can cause major physician errors.

March 4, 2020

Annual Perspective

Patient Safety in Primary Care

February 21, 2020

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.

August 28, 2019

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

August 21, 2019

Performing an inadvertent procedure.

January 30, 2019

WebM&M Cases

Written Signout: It Only Works If You Use The Right One

November 1, 2018

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

October 24, 2018

Potential biases in machine learning algorithms using electronic health record data.

August 29, 2018

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

February 8, 2017

Context-sensitive decision support (infobuttons) in electronic health records: a systematic review.

August 31, 2016

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.

July 20, 2016

Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program.

June 22, 2016

An observational study to evaluate the usability and intent to adopt an artificial intelligence–powered medication reconciliation tool.

June 8, 2016

Missing clinical and behavioral health data in a large electronic health record (EHR) system.

May 11, 2016

Interview

In Conversation With… Vineet Arora, MD, MAPP

September 1, 2015

Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues.

March 18, 2015

Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical education.

September 17, 2014

Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation.

August 13, 2014

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

April 30, 2014

Electronic handoff instruments: a truly multidisciplinary tool?

April 9, 2014

We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.

March 19, 2014

See More About The Topic

Hospitals

Physicians

Quality and Safety Professionals

Information Professionals

General Internal Medicine

Time to sign off on signout.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Time to sign off on signout.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site