Focusing on Sign-Outs


Developing Criteria to Improve Our Sign-Out Practices

It has long been recognized that errors can occur during the transfer of care. Despite this, there has been a relative paucity of significant efforts to improve and standardize sign-out techniques.

As hospitals across the country have decreased the number of consecutive hours that resident physicians are scheduled to work in response to the mounting scientific evidence of the dangers of resident fatigue, the frequency of patient hand-offs has inevitably increased. Some warn that these additional hand-offs will only contribute to more medical errors. Yet a recent randomized control trial showed that: the error rate associated with fatigue outweighed the error rate associated with increased hand-offs (NEJM. 2004; 351(18): 1838-1848).

Improving the patient hand-off process is essential to maximizing patient safety. A recent survey of residency programs noted that 55% did not consistently require both a written and oral sign-out. Sixty percent failed to provide training or workshops on sign-out skills (Arch. Intern. Med. 2006; 166:1173-1177).

The Committee of Interns and Residents, the nation’s oldest and largest union of resident physicians, recently conducted an informal survey of sign-out systems across a number of hospitals and specialties, and found variability in sign-out requirements, infrastructure, computer-guided support, and technique. There is clearly a need to train for, improve, and standardize sign-out procedures and to provide adequate support to properly transfer care of patients. Furthermore, in 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added patient hand-offs as an area for examination (JCAHO 2007 National Patient Safety Goals, 2E). The following is a compilation of suggestions to assess and improve sign-out systems.

 Sign-outs should, at a minimum, comply with JCAHO standards and:

  • be both written and oral 
  • occur face-to-face
  • be interactive, with time for questions, responses, confirmation, and feedback
  • be supervised by higher levels of the team and involve as much of the team as possible
  • be inter-specialty, where appropriate
  • be interdisciplinary (e.g. include RNs, PAs and other professionals) when feasible and include notice to RNs of changed coverage and responsibilities
  • be standardized within and, as much as possible, across departments
  • be computerized
  • be done in coordination with electronic access to patient records and data
  • occur in a location and at a time free of interruptions
  • be a formally trained and evaluated skill (including experiential workshops and didactics) that includes monitoring the quality of the process
  • result in identifying the sickest patients and giving notice to RNs and other staff so they can anticipate problems
  • be subject to regular re-evaluation and improvement

Towards a Systematic Review of Best Practices for Sign-Outs

These recommendations are meant to serve as an initial guide for assessing sign-outs for potential areas of improvement, and also to help generate discussions within departmental and hospital committees. Within the overall movement for consistency and a systems approach to sign-out, each residency program may have unique needs and not all of the recommendations may be appropriate.

There is a pressing need for a more systematic review and assessment of best practices. Hospitals and programs need to develop and share unique sign-out curriculum and workshops. Systematic hand-overs and sign-outs occur in many industrial and professional situations — it is surprising that such a critical event in hospital-based patient care settings is performed in such an inconsistent manner, and with little or no training.

The growing body of data strengthens the case for shorter resident work hours to improve both patient and resident safety, and enhance resident learning. Because hand-offs and sign-outs have been long ignored as a critical moment in patient care, they have now become identified as a weak point. This “weak point” should not be allowed to be used by traditionalists as an excuse for longer hours.

To ensure safe transfers of care, we must take the lead and join with responsible hospital leaders to more carefully examine and improve the sign-out system.