• Cases & Commentaries
  • Published November 2018

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

The Case

A 75-year-old man was hospitalized due to a stroke. During the hospitalization, he experienced significant difficulty swallowing, which resulted in an aspiration pneumonia. He then developed hypernatremia (high blood sodium levels) requiring close monitoring and treatment with IV fluids.

The patient was hospitalized at an academic hospital early in the academic year. At this institution, all housestaff received training in safe handoffs using a standardized, validated tool (I-PASS), and the electronic health record (EHR) had a dedicated signout template. However, the primary intern caring for the patient was on his first day of the rotation, as was the night cross-cover intern. Before leaving for the day, the primary intern reviewed the overnight plan with his senior resident and attempted to update the signout template in the EHR. He then verbally signed out to the cross-cover intern, asking her to check the patient's sodium level and replete the patient with IV fluids if the sodium was elevated. The cross-cover intern asked for more specific directions around managing the patient's sodium, and the primary intern assured her that the necessary information was in the written signout. The cross-cover intern was already very busy receiving signout from other interns, so she did not specifically review the detailed written instructions with the primary intern.

Later that evening, the patient's sodium level test result returned at 144 mmol/L (the upper limit of normal). The cross-cover intern checked the written signout, which stated "If Na >142 then give 1 liter half normal saline." The cross-cover intern reviewed this plan with her supervising resident, who agreed; she then wrote an order to give the IV fluids as instructed.

The following morning, the primary team returned and received signout from the cross-cover intern. The primary team's senior resident expressed surprise when she was told that IV fluids had been started overnight and remarked, "He was getting volume overloaded yesterday, so we didn't want any fluids started unless he was definitely hypernatremic. A sodium of 144 mmol/L is fine—you shouldn't have done anything." The cross-cover intern was confused and pointed out that she had followed the written signout instructions. On reviewing the written signout, the primary intern realized that he had accidentally printed a copy of the previous day's signout—it had not been updated. The sodium management plan had actually been changed, but this was not reflected in the printed written signout.

Fortunately, the patient did not experience any adverse consequences as a result of the error. After reviewing the incident, the residency program decided that a senior resident should review the written signout and should be present when interns sign out to each other for the first 3 months of the academic year.

The Commentary

by Kheyandra Lewis, MD, and Glenn Rosenbluth, MD

Effective communication is essential to the delivery of optimal patient care. The critical exchange of information and transfer of patient care responsibility that occurs in handoff is particularly vulnerable to communication errors.(1) Miscommunications, such as omission of data or transfer of inaccurate information due to inadequate handoff, pose a risk to patient safety and have been linked to sentinel events reported to The Joint Commission.(1) Increased recognition of medical errors attributable to poor handoff communication stimulated regulatory bodies to broaden their focus to include this important domain. In 2006, The Joint Commission established a National Patient Safety Goal focused on handoffs.(1) Responding to the increased frequency of resident handoffs created due to duty hours restrictions and a growing research base, in 2011 the Accreditation Council for Graduate Medical Education (ACGME) required residency programs to provide formal training and supervision in handoff communication.(2)

In the above case, the resident team received handoff training using a standardized, validated tool—I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver). I-PASS provides an organizational framework for both verbal and written handoff communication and represents a foundational element of an evidence-based handoff bundle.(3) The I-PASS Handoff Bundle includes a workshop that teaches teamwork and communication skills (using TeamSTEPPS) as well the I-PASS handoff mnemonic, role-plays and simulations, a learning module for independent study, faculty development, direct observation tools, and a campaign to impart elements of cultural change and sustainability.(3-5)

Implementation of the I-PASS Handoff Bundle on the inpatient units at 9 pediatric training programs was associated with a 23% decrease in medical errors and a 30% reduction in preventable adverse events.(4) Standardized handoff approaches like I-PASS help maintain consistency in provider-to-provider transfer of verbal and written information and promote active dialogue.(6) Adaptation of the I-PASS Handoff Bundle in both a pediatric community setting and pediatric teaching unit resulted in improved collaborative discussions to identify errors and enhanced contributions between providers in the development of management plans.(7,8) In addition, resident handoff documents more frequently included key elements like clinical status and contingency plans after I-PASS implementation.(7)

Another integral attribute of a structured handoff framework is the opportunity for receiver synthesis (sometimes called "teach-back" or "check-back"). Synthesis by receiver creates the conditions for the receiving provider to verbalize understanding and the giving provider to correct misunderstandings.(3,5) Unfortunately, despite inquiring, the receiving resident in this case was unable to effectively convey understanding of the plan because synthesis was not adequately used. Having an updated written handoff document at the time of verbal handoff could have helped prevent the transmission of inaccurate information regarding the hypernatremia management plan.(4) However, the written document still has the potential for errors as it relies on real-time updates to avoid outdated information.(9) It is important to note that both verbal and written handoff communication are necessary as they are complementary—a verbal handoff does not provide a guided reference for discussion when used alone.

Integration of handoff documents into electronic health records (EHRs) can help decrease transcription errors and time used for data collection.(8) However, once a handoff document is printed, it becomes static and subject to inaccurate information. Therefore, consistent upkeep is required.(9) Furthermore, providers should be cautious against inadvertent omission of information due to character limits or excessively lengthy documents due to printing formats.(8,10) As constant interfacers with patient care and EHR, residents can offer valuable input on techniques to create integrated written handoff documents. One strategy to improve the integrity of the written handoff is to designate a senior team member to update the written document, removing the uncertainty in team member task responsibility.(10)

As seen in the case, the use of a structured format is not enough to ensure best practices in handoffs and prevention of medical errors. It is crucial that residents, especially new residents, are supervised in handoff, as residents tend to overestimate the quality of their handoffs.(11) Supervision of handoff by faculty is essential in providing timely and direct feedback and reinforcing good behavior. It also fulfills the ACGME requirement "that Programs, in partnership with their Sponsoring Institutions, must ensure and monitor effective, structured hand-over processes."(2)

Regardless of the handoff bundle chosen, institutional leaders must commit to shared cultural and procedural change with input from all stakeholders. Having a budget to maintain necessary resources and allocating time for training and direct observation to assess correct use and ensure sustainability is vital. Additional layers of support include available workspaces near patient care areas where handoff can occur with decreased noise and limited distractions and readily available technology that can be used to view associated learning modules and create written handoff documents. Direct modeling and designation of both faculty and resident champions can aid in maintaining engagement. Residents should be introduced early in discussions about planning and executing implementation of handoff bundles.(10) Resident level–specific training may help delineate new skills and support junior residents while also refining and augmenting leadership skills for seniors.(10) In an ideal state, all residents on a care team would engage in a single combined handoff routinely, especially when cross covering. If the residents in this case had a combined handoff, an error might have been prevented.

The use of structured handoff frameworks, such as I-PASS, provide organization and consistency in both verbal and written communication during provider transitions. With guided ongoing supervision and directed feedback, provider teams can use this framework to promote active discussions during handoffs, thereby identifying and reducing medical errors.

Take-Home Points

  • Structured handoff frameworks, like the I-PASS Handoff Bundle, provide organization and consistency in provider transitions and can decrease provider miscommunication reduce medical errors.
  • Written and verbal handoff are complementary; written documents serve as a reference and can reinforce active verbal discourse to promote shared understanding between providers.
  • Teaching handoff skills is important, and skills should be maintained through routine direct supervision and feedback.

Kheyandra Lewis, MD
Attending Physician, Section of Hospital Medicine
Assistant Professor of Pediatrics, Drexel University College of Medicine
St. Christopher's Hospital for Children
Philadelphia, PA

Glenn Rosenbluth, MD
Clinical Professor of Pediatrics
University of California San Francisco
UCSF Benioff Children's Hospital

References

1. Sentinel Event Alert. Inadequate hand-off communication. September 11, 2017;(58):1-6. [go to PubMed]

2. ACGME Common Program Requirements. Accreditation Council for Graduate Medical Education. [Available at]

3. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129:201-204. [go to PubMed]

4. Starmer AJ, Spector ND, Srivastava R, et al; I-PASS Study Group. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;372:1803-1812. [go to PubMed]

5. TeamSTEPPS. Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality. [Available at]

6. Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310:2262-2270. [go to PubMed]

7. Huth K, Hart F, Moreau K, et al. Real-world implementation of a standardized handover program (I-PASS) on a pediatric clinical teaching unit. Acad Pediatr. 2016;16:532-539. [go to PubMed]

8. Walia J, Qayumi Z, Khawar N, et al. Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program. Acad Pediatr. 2016;16:519-523. [go to PubMed]

9. Rosenbluth G, Jacolbia R, Milev D, Auerbach AD. Half-life of a printed handoff document. BMJ Qual Saf. 2016;25:324-328. [go to PubMed]

10. Coffey M, Thomson K, Li SA, et al. Resident experiences with implementation of the I-PASS handoff bundle. J Grad Med Educ. 2017;9:313-320. [go to PubMed]

11. Chang VY, Arora VM, Lev-Ari S, D'Arcy M, Keysar B. Interns overestimate the effectiveness of their hand-off communication. Pediatrics. 2010;125:491-496. [go to PubMed]

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