• Leora I Horwitz, Tannaz Moin, Harlan M Krumholz, Lillian Wang, and Elizabeth H Bradley.
• Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 789 Howard Ave, New Haven, Connecticut 06519, USA. horwitz@yale.edu
• Arch Intern Med. 2008 Sep 8; 168 (16): 1755-60.

BackgroundIn case reports, transfers in the care of patients among health care providers have been linked to adverse events. However, little is known about the nature and frequency of these transfer-related problems.MethodsWe conducted a prospective audiotape study of 12 days of "sign-out" of clinical information among 8 internal medicine house-staff teams. Each day, postcall and night-float interns were asked to identify any sign-out-related problems occurring during the coverage period and to identify the associated sign-out inadequacies. We verified reported sign-out inadequacies by reviewing each corresponding oral and written sign-out. We then developed a taxonomy of types of errors and their consequences through an iterative coding process.ResultsSign-out sessions (N = 88) included 503 patient sign-outs. A total of 184 patients were signed out twice in the same night. Thus, there were 319 unique patient-days in the data set. We interviewed intern recipients of 84 of 88 sign-out sessions (95%) about sign-out-related problems. Postcall interns identified 24 sign-out-related problems for which we could verify sign-out inadequacies. Five patients suffered delays in diagnosis or treatment, resulting in 1 intensive care unit transfer, and 4 patients had near misses. In addition, house staff experienced 15 inefficiencies or redundancies in work. Sign-outs omitted key information, such as the patient's clinical condition, recent or scheduled events, tasks to complete, anticipatory guidance, and a specific plan of action and rationale for assigned tasks.ConclusionOmission of key information during sign-out can have important adverse consequences for patients and health care providers.

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