A Precarious Exchange

What an interesting article in bringing up a salient point.

To a physician, this scenario is all too familiar “” we call it “sign-out” “” but in a way, the anthropologist would be right: it is a peculiar ritual, this daily transfer of patients from one medical team to another. As I write this, at the end of a frantic afternoon, 18 residents are simultaneously handing off patients to one another in the noisy emergency room. In the medical units of the hospital, hundreds of such exchanges happen every week. And yet, ubiquitous as the sign-out is, it remains one of the most poorly examined transactions in medicine . . .

In 1994, a team led by Laura Petersen examined this sort of question in a rather simple experiment: they followed 3146 patients admitted to a medical service and recorded the preventable errors that occurred.1 When the investigators explored the risk factors for errors, they found something remarkable: coverage by a second team of physicians was one of the strongest predictors “” almost three times as likely as coverage by a single team to correlate with an adverse event.

These results are even more salient today. Since July last year, residency programs have begun to ease into the 80-hour workweek “” a stringent set of regulations mandated by the American Council for Graduate Medical Education (ACGME) that restricts working hours for residents and interns. That regulation means more physicians rotating through shifts, more cross-coverage, more sign-outs “” and more opportunities for error. And there, perhaps, lies the rub: the new work regulations are supposed to make medicine safer by decreasing the number of overworked, sleepy doctors. Ironically, it may be precisely these changes that expose patients to errors made in the process of handoff.

Since physician teams cannot cover a given hospital patient 24-hours a day, the ritual of “sign-out” is critical. Whether it is from the day-shift to night-float or the post-call team to the on-call team, it is not uncommon for hospitalized patients to have 2 to 3 separate physician teams responsible for their care in a single day. Therein lies the danger. Like a game of “broken telephone”, communication between teams offers a dangerous time for details to slip through the cracks. The art of “signing out” becomes all the more important since residency programs are strictly enforcing the 80-hour per week work rule. Similar to a relay – the more handoffs that are required, the greater the chance the baton is dropped.

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