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PSNet: Patient Safety Network

 Cases & Commentaries

Fumbled Handoff

Commentary By Arpana Vidyarthi, MD

The Case

A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and chronic renal insufficiency was admitted for an elective sigmoid resection and diverting colostomy. On postoperative day (POD) 2, the patient was tachycardic, despite receiving a low-dose beta-blocker. That same day, she informed her nurse that she had developed left leg pain. Assuming it was related to the epidural placed preoperatively, the nurse called anesthesia, and they responded by decreasing the epidural rate. The primary surgical team was not called at that time. On POD 3, the patient had no complaints for the primary team on morning rounds. Later in the evening, the cross-covering intern was called concerning the left leg pain. No information about this intern's findings was relayed to the primary team the next morning. On POD 4, the patient complained to the nurse of mild chest discomfort. She was seen by housestaff within 20 minutes and by the attending several hours later. Her exam was unremarkable. A workup was initiated, but within an hour of the attending's visit, the patient's blood pressure dropped to 70/40, followed shortly thereafter by a pulseless electrical activity (PEA) arrest, from which she could not be resuscitated. Post-mortem examination revealed pulmonary embolism.

The Commentary

This patient's poor outcome occurred in part due to a breakdown in communication between physicians. The transfer of patient data and care responsibility is commonly referred to as a "signout", "passoff", or "handoff." In this case, several problems seem to have contributed, perhaps the most glaring being an error of omission in the signout.

Discontinuity in the care of hospitalized patients is a necessity. No physician can be in the hospital 24 hours a day, 7 days a week. Anyone who has ever drawn up a physician or nursing schedule recognizes the stark truth: hours worked and numbers of signouts are inversely related—the fewer hours one is in the hospital, the more times patient care needs to be transferred. For anyone who has watched children playing "Telephone"—a game in which a message whispered in succession is, by the time it reaches the end of the line, nearly always distorted to something completely different—the inherent potential for error due to signouts is obvious. Unfortunately, the process of signout usually fails to account for the inevitability of human error.

Signouts have taken on new importance in the era of resident duty hour restrictions. In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented mandates reducing resident duty hours to 80 per week, with no more than 30 consecutive hours worked.(1) These mandates have increased the number of signouts and resultant discontinuity for hospitalized patients across the board.(2) Ironically, a regulation attempting to reduce mistakes made by over-worked physicians could theoretically increase mistakes due to discontinuities in care. In a survey at our institution, nearly half of residents identified the increased numbers of signouts and resultant potential for harm to patients as the main problem with the reduction in work hours (A.V., unpublished data, 2004). Like transfers between institutions or between the inpatient and outpatient setting, in-hospital signouts represent gaps in care and thus demand increased vigilance to avoid placing patients at increased risk for harm.(3) Although practitioners are generally effective in bridging gaps, in this case the measures they took were not enough.

Signouts do not occur in a vacuum. Physicians are undoubtedly influenced by their own sense of the importance of various pieces of data, their memories of past cases, and their own communication skills. Moreover, signouts are carried out in a culture unique to their hospital or training program. Even thorough and succinct verbal signouts are often conducted in interrupted environments, such as at the nurses' station, in the operating room, amidst answering pages, etc. These interruptions carry a psychological cost—diversion of attention, forgetfulness, and errors.(4)

The written aspect of the signout, which one might deem more reliable and impervious to outside influences, can be inconsistent, incomplete, and, at times, inaccessible. In one study, simple information like age and sex was reported incorrectly.(5) In another, necessary information such as code status and allergies was missing in 80% of written signouts.(6) In yet a third, the signout sheet itself was noted to be lost 25% of the time (V. Aurora, unpublished data, 2004). Given human factors, cultural norms, disruptions during verbal communication, and the inadequacies of the written signout, it is not surprising that information is often lost during information transfer.

Communication breakdown and discontinuity of care have deleterious effects on patients. Of the 25,000-30,000 preventable adverse events that led to permanent disability in Australia, 11% were due to communication issues, in contrast to 6% due to inadequate skill levels of practitioners.(7) In one study, being covered by the "cross-coverage" resident was a powerful risk factor for preventable adverse events.(8) Decreasing duty hours in New York in 1989, with the inevitable increase in discontinuity and increase in sign-outs, resulted in delayed test ordering and increased in-hospital complications.(9) Patients were more satisfied with care when admitted by their primary team as opposed to the cross-coverage team.(10) In a study of increasing senior resident continuity, researchers found fewer medication errors, as well as a decrease in length of stay and number of laboratory tests ordered.(11)

Approaching signouts as a "systems issue" will require that we observe the sign-out process at each hospital or training program, and engage those at the sharp end—the housestaff and attendings who engage in signouts—to describe the system's vulnerabilities and provide potential solutions. The signout process itself should be standardized. Data suggests that using checklists (5), signout cards (6), and computerized signouts (12) can increase the quality, reliability, and accuracy of information as well as satisfaction of the users. Verbal techniques such as "read-backs" (the listener repeating back salient issues) have been successful in aviation (2), and should be instituted as a standard part of the signout process. Another technique—increasing redundancy—should be implemented. Specifically, the chart should act as the database for all information, and any change in status of a patient should be clearly documented in the chart. For instance, cross-coverage notes should be written consistently and be explicitly identified as such. Education at each of these steps, often accompanied by systems redesign (eg, computer- or PDA-based tools for structuring signouts), will be necessary. These steps might allow both patients and providers to derive the intended benefits from limitations on work hours.

Take-Home Points

  • Discontinuity in the hospital is inevitable.
  • Discontinuity may be increasing in teaching hospitals due to new duty hours mandates.
  • The sign-out process should be standardized to include the following:
    • Change of culture to more obviously value the thorough signout.
    • Verbal signout training and use of read-backs.
    • Structured written information that must be included during signout.
    • A central repository [the patient's chart] where all patient contacts are documented.
    • Use of information technology to assist in the information transfer.

Arpana Vidyarthi, MD, Assistant Professor of Medicine Associate Director for Research, Graduate Medical Education University of California, San Francisco


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