This study of oral and written sign-outs about medicine inpatients found that key clinical information was available just two thirds of the time in either the oral or written sign-out. Less than one third of oral patient sign-outs or written patient sign-outs included the minimum content of: the current clinical state of the patient, any description of the hospital course and a statement as to whether or not there were tasks to be performed overnight. Furthermore, vague and open-ended language was common, while 22% of sign-outs conducted in sequence mischaracterized or omitted information from the previous sign-out. Although in theory oral communication provides an opportunity for interactive dialogue to correct unclear or omitted information, in practice we observed that questions, suggestions, disagreements and read-back were relatively rare. These gaps in information flow during the sign-out process highlight the substantial potential for near misses and medical errors due to transfers of care.
An important feature of our data is that these content omissions were neither random, nor solely dependent on individual skill, but rather were systematically affected by broader structural and cultural conditions: the organization and infrastructure of the hospital, norms about autonomy and responsibility, and the collective understanding of the purpose of sign-out.
A major organizational factor in sign-out quality was the design of the coverage schedule to require two sequential sign-outs in the span of a few hours. This arrangement, a common response to the need to limit resident work hours,34
increased the complexity of the sign-out process and thus the opportunity for error.35
The sequential nature of the sign-outs also meant that sign-outs to the night float, who cared for the patient most of the night, were most often performed by covering physicians unfamiliar with the patients. Providers unfamiliar with patients they were signing out were less likely to include key clinical information than the patients’ primary team members, and were frequently unable to answer recipients’ questions.
The hospital’s information technology infrastructure also affected sign-out quality. Because the institution lacked a fully-templated written sign-out, some written sign-outs contained scant information. In turn, this reduced the comprehensiveness of the oral sign-out, which depended on the written sign-out as a memory aid. Both the night float system and the IT infrastructure were institutional-level factors that embedded obstacles to comprehensive information transfer in the sign-out process, despite great individual efforts to work around these obstacles (such as by providing detailed handwritten annotations every day to the computer-generated sign-out).
Organizational culture was no less important. At this institution, the norm was to have interns sign out without residents present. Consequently, most sign-out sessions did not incorporate senior residents’ greater clinical experience. When senior residents were
involved, sign-outs were more likely to include important information such as the clinical condition of the patient. Finally, sign-out recipients were generally passive rather than active participants in patient care. This may have resulted from a culture of deference and reluctance to criticize colleagues36
combined with a misconception of sign-out as a one-way transfer of information, not as a moment to reflect critically upon the primary team’s diagnoses, actions and plans. The vulnerability of transitions to error was thus increased because recipients did not take full advantage of opportunities to clarify confusing statements, ask for plans or anticipatory guidance, and make suggestions.
Our direct observation study confirms results of earlier interview studies, which found that omitted content was common, language was unstructured and informal, written sign-outs were outdated, night float was problematic, and covering doctors were often uncertain about patient care decisions when covering overnight.1, 4, 8, 9, 27, 37–39
We did not, however, find evidence to support some contextual factors affecting communication that have been noted in other studies. Reluctance to criticize authority and a desire to impress more senior staff have been described as interfering with good sign-out communication.8
We did not observe any marked effect of hierarchy, perhaps because few sign-outs involved senior residents, and even these did not involve staff more than one or two years senior to interns. Likewise, high workload, interruptions and background distractions have been shown to interfere with good communication;8, 28
these were not evident factors in this analysis, perhaps because each sign-out session was relatively brief. Coiera and colleagues, for example, observed an interruption by call or page on average every 18.5 minutes;28
the average sign-out session in this study was less than 5 minutes.
Our study was limited by the nature of the observation; because we had only audiotapes, we were not able to capture non-verbal communication and cues that might have revealed other factors contributing to sign-out quality. In addition, several participants commented that the presence of the tape recorder led to more comprehensive sign-outs than were typical. The measures we used to measure quality were derived from a separate analysis of these data5
and expert opinion,19–25
and have not otherwise been proven to correlate with patient safety. The study was conducted at one institution in one specialty and may not be generalizable to other institutions, call structures, written sign-out formats and specialties. The timing of the study – late spring – meant both that interns had more experience, but also that residents were less often present to supervise. Finally, the limited number of sign-outs involving residents may have reduced our ability to observe effects of hierarchy and experience, and the limited number of interruptions prevented us from assessing the effect of environment.
Our findings have important implications for efforts to improve sign-out. Many recommendations for improving communication between providers focus on ensuring that sign-out includes key information.19–21
Information transfer is clearly lacking in current practice and efforts such as standardization of oral and written content are vital. Nonetheless, because multiple factors beyond individual performance affect the likelihood with which key information is included, focusing on individuals is not sufficient.40
Asking a sign-out provider always to mention the patient’s clinical condition, for example, is of limited value if 1) the provider is not familiar with the patient, 2) the provider lacks the clinical experience to recognize and transmit a worrisome change of condition and is not supervised by anyone with more experience, 3) the second in a series of providers forgets what the first one said because the night float system requires multiple handoffs in a row, or 4) the recipient does not demand the information when it is missing because cultural norms emphasize deference and prevent listeners from considering themselves an integral part of the patient’s care team. Thus, reducing structural and cultural obstacles to good sign-out will be important additions to existing efforts to standardize sign-out communication.24, 33, 41
Handoffs serve a number of purposes beyond the transfer of clinical information, including teaching, promotion of team cohesion, emotional support, socialization, maintenance of social order, and error detection.29–31, 42, 43
On occasion these goals conflict, as when promotion of team cohesion is prioritized over error detection, so questioning is discouraged. Yet the multitude of purposes served by sign-out is also an advantage. The socialization and training aspects of sign-out, for example, could be harnessed to foster the development and maintenance of a sign-out culture that prioritizes and enhances patient safety.39
The team-building component of sign-out could be reconfigured from a model in which the sign-out recipient is someone who just “holds the fort,” to a model in which all sign-out participants are equal members of a team bearing equal responsibility for the patient. Such a reframed sign-out culture would help promote a “new” professionalism, defined not as the duty to stay with the patient at all times but as the duty to ensure the best care for the patient no matter who is in the hospital.16