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Missed Patient Assignment: Is Anyone There?

Dean F. Sittig, PhD; Emily Campbell, RN, MS, PhD; Hardeep Singh, MD, MPH | August 1, 2010
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The Case

In one hospital, nurses' patient assignments were communicated by listing the room numbers next to each nurse's name in a computerized tool. At the beginning of a new shift, the oncoming nurses listen to the taped report for each patient in their assigned rooms.

At the start of one particular evening shift, a nurse was assigned five rooms to cover per the paper assignment list. However, the taped report for one of the bed locations was empty. She concluded that the room had been vacated and was now available for a new admission or transfer.

The nurse made rounds on each of the patients for whom she had a report at the beginning of the shift, completing the assessments, medications, and treatments for each one. Mid-shift, the charge nurse inquired if there were any status changes or other pertinent information regarding any of the assigned patients. The nurse stated that there were none. Near the end of the shift, the nurse recorded a report on her four patients. At the end of the shift, the charge nurse asked why there wasn't a taped report on the fifth assigned patient.

This came as a surprise, as the nurse had never seen the fifth patient. She quickly visited the patient and completed necessary assessments and care. Fortunately, the patient was stable, was scheduled to be discharged in the morning, and had not been scheduled to receive any medications or tests during that shift. He was not harmed.

The concern for this neglected patient and the potential for similar events in the future led to a root cause analysis. The underlying cause was determined to be the lack of confirmation of patient assignments by the accepting nurse. There were multiple contributing causes. On this unit and throughout the hospital, there were varying procedures for creating, checking, and distributing nursing assignment lists by different charge nurses and different, or sometimes no, methods for acknowledging assignments.

As a result, a rapid cycle improvement was conducted, and its recommendations were implemented on all inpatient units. First, nurses were to do an independent double-check of the nursing assignment list made by the charge nurse using consistent symbols with standardized meanings. Second, at shift change, oncoming nurses would be required to enter their own names next to the names of patients they had been assigned in the electronic patient tracking tool. This would acknowledge communication of assigned patients. Lastly, the charge nurse would compare the assignment list to the completed electronic sign-in tool and address any discrepancies.

The Commentary

Changing critical communication from synchronous to asynchronous can be a safety hazard. This adverse event is an excellent example of an unintended consequence that occurred when a portion of a complex clinical process was replaced by technology. An added complexity was the transformation of a previous synchronous, face-to-face communication event into an asynchronous, technology-enabled, tape-delayed event. While the latter technique certainly has advantages for facilitating handoffs, it might also result in errors because some or all of the information may appear to have been effectively conveyed, even though it wasn't, in what has been called "the illusion of communication."(1) Therefore, when communication processes change from synchronous to asynchronous, one must ensure a "fail-safe" mechanism for identifying, tracking, and escalating (i.e., passing the message and the responsibility for its response to another person until its receipt is confirmed) information in anticipation of failures to communicate.

New technologies seek to improve, as measured in the broadest sense, on existing processes. Therefore, the designer and implementer must not only understand the existing processes' strengths and limitations (2), but also gain an in-depth understanding of the strengths and limitations of the new technological solution.(3) We have created the following eight-dimension, socio-technical paradigm of "safe and effective health information technology implementation and use," which can be used before these solutions are implemented as well as to help investigators analyze problems following implementation involving, for example, technology-based communication in clinical settings (Table).(4,5)

We now describe how the eight dimensions could be applied to further understand the technological as well as nontechnological issues that surround this case:

Hardware/software: The hardware and software chosen must be highly reliable, widely available, and easy to use. The tape recorders used in the reported adverse event, like written index cards left for oncoming physicians in some handoffs, clearly met some of these goals, but did not sufficiently address all "fail-safe" requirements (e.g., confirmation of transfer of responsibility, ensuring that the message was received and understood, or provision of a reliable escalation procedure in the event that the anticipated communication did not occur) (6) and thus failed as a single solution to a multidimensional problem.

Content: Solutions to this transition of care problem should facilitate the collection, organization, and documentation of the information (i.e., the content) to be communicated. For example, clinicians need a common, partially structured data interchange format that ensures that all critical information is available, clear, understood, and documented. Ideally, this information would be collected from multiple locations within an integrated state-of-the-art electronic health record (EHR) system and either printed or displayed on the screen for the users.

User interface: The user interface (UI) of the chosen technology must be easy to access and use. It should require confirmation of a complete and accurate handoff by the off-going clinician as well as receipt of all patients by the oncoming clinician. Care must be taken to avoid the "illusion of understanding," which can occur when highly trained, conscientious clinicians make simple mistakes or completely miss or fail to comprehend key abnormal laboratory results or vital signs that are clearly displayed, and even flagged, on a well-formatted, highly readable screen or legible paper report.(7) For critical care situations, it may be necessary to require that clinicians actively acknowledge key information either on a paper form or in the EHR to ensure that it has not been overlooked. The system should also provide its users adequate data for further improvement—for instance, a daily monitoring report to the charge nurse that includes the elapsed time for each RN to complete the handoff procedure, the mean for the entire unit, and monthly means for this unit and the overall mean for the entire organization. In addition, it should account for user vulnerabilities, such as generation of a fail-safe alert in the EHR to a designated person if the handoff procedure is not completed (e.g., if the RN handoff is not acknowledged for any patient within 2 hours of shift change). Finally, the UI should provide an overview of key patient-related data including a list of all patient problems, medications given and ones that are due, family contact information, resuscitation status, etc.(8) The tape recorder–based solution did not provide any of these features.

People: When technology-driven processes replace previous face-to-face communication processes, the needs of the people involved must be carefully considered during all stages of development and implementation. In this case, the clinicians involved need to quickly build rapport and assess each other's clinical knowledge, experience, and technical capabilities.(9) These issues are usually not addressed to the extent needed in clinical practice.

Workflow and communication: Strategies to make the asynchronous processes more synchronous and active are needed. For example, a process that involves both shift-change clinicians walking together into each of the off-going clinician's patients' rooms carrying and referring to a computer-generated, and human-annotated, sheet containing key clinical data—perhaps available via a handheld computer—would maximize the transfer of information without adding unnecessary time to the existing clinical workflow.(10)

Internal organizational policies and procedures: The organization's policies must be modified to sanction and reinforce the social and technical changes that are made. For example, it may be necessary to assign a person responsible for monitoring the change-of-shift assignment report as well as a back-up person who can be reached if the first person, for any reason, does not acknowledge that all patients are properly accounted for.

External rules and regulations: The Joint Commission recommends that each organization's:

"process for effective hand off communication includes: interactive communications allowing for the opportunity for questioning between the giver and receiver of patient information; up-to-date information regarding the patient's care, treatment and services, condition and any recent or anticipated changes; a process for verification of the received information, including repeat-back or read-back, as appropriate; an opportunity for the receiver of the hand off information to review relevant patient historical data, which may include previous care, treatment and services; [and that] interruptions during hand offs are limited to minimize the possibility that information would fail to be conveyed or would be forgotten."(11)

All of these concepts are critical for the safe and effective transfer of patients from one caregiver to the next. Once again, the tape recorder–based solution did not guarantee any of these items.

System measurement and monitoring: Any new process should have specific measurements identified, implemented, and regularly monitored to ensure that the process is working as expected and is safe and effective. For example, one could measure and regularly report on certain measures of the safety of the handoff process using the new technology as well as monitor the percentage of nurses requesting overtime to ensure that the new process does not unduly increase the workload.

Take-Home Points

  • Face-to-face communication is one of the most effective methods known for: (i) sending a message, (ii) ensuring it is received, and (iii) ensuring it is understood. Therefore, whenever technology of any kind is implemented in a manner that changes a face-to-face encounter to an asynchronous event, extreme care must be taken to ensure that these three components of safe and effective communication are maintained.
  • Partial solutions to complex multidimensional problems often fail. Great care must be taken when embedding technology, whether it is as simple as a tape recorder or as multifaceted as a comprehensive electronic record system, within a complex health care process.
  • Potential errors resulting from replacing existing human-based processes with new technology must be tracked. If technological solutions create potentially dangerous situations, their use should be curtailed until the identified problem(s) can be resolved.

Dean F. Sittig, PhD University of Texas—Memorial Hermann Center for Healthcare Quality & Safety

School of Biomedical Informatics

University of Texas Health Science Center

Houston, TX

Emily M. Campbell, RN, MS, PhD Director of Clinical Informatics

Oregon Anesthesiology Group

Portland, OR

Hardeep Singh, MD, MPH Houston VA HSR&D Center of Excellence and the Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication

Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research

Department of Medicine

Baylor College of Medicine

Houston, TX


1. Sittig DF, Ash JS. Clinical Information Systems: Overcoming Adverse Consequences. Sudbury, MA: Jones and Bartlett; 2010. ISBN: 9780763757649.

2. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-407. [go to PubMed]

3. Safely implementing health information and converging technologies. Sentinel Event Alert. December 11, 2008;(42). [Available at]

4. Sittig DF, Singh H. Eight rights of safe electronic health record use. JAMA. 2009;302:1111-1113. [go to PubMed]

5. Singh H, Thomas EJ, Mani S, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med. 2009;169:1578-1586. [go to PubMed]

6. Clark HH. Using Language. Cambridge, UK: Cambridge University Press; 1996. ISBN: 9780521561587. [Available at]

7. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123:238-244. [go to PubMed]

8. Strople B, Ottani P. Can technology improve intershift report? What the research reveals. J Prof Nurs. 2006;22:197-204. [go to PubMed]

9. Klein G, Feltovich PJ, Bradshaw JM, Woods DD. Common ground and coordination in joint activity. In: Rouse WB, Boff KR, eds. Organizational Simulation. New York: Wiley-Interscience; 2004:139-184. ISBN: 9780471681632. [Available at]

10. Laws D, Amato S. Incorporating bedside reporting into change-of-shift report. Rehabil Nurs. 2010;35:70-74. [go to PubMed]

11. Joint Commission on Accreditation of Health Care Organizations. 2007 National Patient Safety Goals Hospital Version Manual Chapter, including Implementation Expectations. [Available at]


Table. Overview of the Eight-Dimension Socio-technical Model of Safe and Effective Electronic Health Record Use.

Model Dimension Brief Explanation
Hardware and software computing infrastructure

Focuses on the hardware and software required to run the applications along with all the machines, devices, and software required to keep the computing infrastructure functioning.

Clinical content

Includes everything on the data-information-knowledge continuum stored in the system (i.e., structured and unstructured textual or numeric data and images).

Human–computer interface

Enables unrelated entities to interact with the system and includes aspects of the system that users can see, touch, or hear.


Humans (e.g., software developers, system configuration and training personnel, clinicians, and patients) involved in the design, development, implementation, and use of HIT.

Workflow and communication

Acknowledges that people need to work with others in the health care system to accomplish patient care.

Internal organizational policies, procedures, and culture

Organizational leaders and committees write and implement IT policies and procedures responsible for overseeing HIT system procurement, implementation, use, monitoring, and evaluation.

External rules, regulations, and pressures

Accounts for the external forces that facilitate or place constraints on the design, development, implementation, use, and evaluation of HIT in the clinical setting.

System measurement and monitoring

Effective measurement and monitoring programs address four key issues related to HIT features and functions: availability, use, effectiveness, and unintended consequences.

HIT, health information technology.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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