To our knowledge, this is the first study to quantitatively report the frequency, type, and harm potential of medication discrepancies between patient charts and resident-written sign-outs on the general medicine service at an academic hospital. Medication discrepancies are common with medication omissions more frequent than commissions. Although medication omissions are more likely to persist, a higher proportion of both index and persistent commissions has the potential to be very harmful. More than half of all discrepancies had the potential to cause significant harm to patients. These results suggest the urgent need to improve current methods of information transfer during patient hand-offs.
However, before improvements can be made, it is important to consider how and why such errors occur, and what their significance is. First, transfers of clinical responsibility occur frequently in hospitals, making it difficult for physicians, including residents, to keep their sign-outs up-to-date on a daily basis. In addition to daily progress notes that physicians write in the medical chart, sign-out is a parallel record that requires daily updates and maintenance. Furthermore, the majority of these index omissions and commissions persist on subsequent days, suggesting that vigilant efforts are not being made to keep the sign-out updated. One possible explanation for the high rate of persistent errors is that residents consider certain medications less important to keep track of, choosing to omit them. This likely explains the finding that persistent errors in omissions were less harmful than those that did not persist. In contrast, it is hard to imagine an intentional commission, which may explain why commissions, when present, are more likely to be serious than omissions.
It is also worth considering these findings and their implications in the context of a broader model of medical information. Whereas technological solutions will likely address medication discrepancies by linking to certain fields such as medications, allergies, and code status from medical records, certain fields which require human input such as pertinent historical data (recent problems, surgeries, recommendations, overnight events, etc.) will still depend on physician updating. This is of critical importance given the ease with which erroneous medical information can persist that is suggested by our findings. Furthermore, a major problem noted with the implementation of medical records is the ease of “cut-and-paste”, suggesting how erroneous outdated clinical information can be perpetuated.7
This discussion highlights the burden that multiple updates impose on clinicians and the difficulty of manually synchronizing different information repositories. Improving the accuracy of sign-out will depend, to a substantial degree, on the ability to consolidate information stores in a single repository and the avoidance of solutions that require manual updates. To that end, encouraging residents to keep a meticulous perfect phantom record of medications on their sign-outs may not be the best use of their time as this information is available in the chart and this process is inherently prone to transcribing errors. It may be a more effective for residents to spend their time updating information that is not readily available elsewhere such as contingency planning, pending test results or consultant recommendations, or tasks to be completed.
This study has several limitations. First, it examines the transfer of clinical responsibility using resident sign-outs at 1 teaching hospital. However, most Internal Medicine residency programs use a similar “low tech” process for generating sign-outs, such that any results from this study would also prove insightful for other locations.12
It is possible that at other institutions, interns use the chart or consult other sources before making initial decisions. At least one other major institution describes that because of the volume of patients being covered and the number of pages received (anywhere from 5 to 20 per hour), interns are making decisions without consulting the chart or directly evaluating patients.8
It was also a sample of 10 interns for 1 month at an academic teaching hospital. However, there was a large sample of medication entries for each intern and patient in which the results do consistently show that there are many medication errors on the sign-out, some of which are potentially harmful. Third, because only the medication list was examined as a measure of sign-out accuracy, it is possible that there were additional details on other parts of the sign-out that were not abstracted. Lastly, the classification scheme does not distinguish between omissions and commissions when rating potential for patient harm, only the routes and classes of medications involved. This may not be a valid approach for this because omissions of a drug (antibiotic) may be more or less serious than a commission of a drug (antihypertensive).
Despite these limitations, it is important to note that the majority of medication omissions and commissions were not trivial, but instead had the “potential to cause moderate discomfort or clinical deterioration”. Because of the large number of omissions and commissions present on the sign-out, this level of potential harm is unacceptable and represents a patient safety threat that needs to be addressed. Focus needs to be placed on system improvements in communication and information transfer. A major systems-level improvement that has already been shown to reduce medication discrepancies is the use of a computerized sign-out system, which can integrate with an electronic medical record.9–12
However, given that this type of technology is not yet available in many hospitals, and evidence suggests that electronic solutions have the potential to increase the rate of medication errors in the short-term,13,14
education and monitoring needs to be a high priority.15,16