Sunday March 19, 2006
Sign-out Mortality !
Regular evening work (sign-out) round is an integral part of all tertiary/teaching ICUs in USA but unfortunately as we transit to private practice or community hospital enviroment, we tend to loose this wonderful tradition. Ever thought about poor sign-out to your colleague as a patient safety issue?. A group pf physicians from Chicago have published their study in Quality and Safety in Health Care.
26 interns caring for 82 patients were interviewed after receiving sign-out from another intern. 25 discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. Ever think of sign-out as a procedure?
Read interesting article related to this topic Glucose Roller Coaster with sample signout sheet at the AHRQ WebM&M website, from Bradley A. Sharpe, MD, University of California, San Francisco .
Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis - Quality and Safety in Health Care 2005;14:401-407