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10 Tips to Minimize Error at ED Sign-Out Rounds

2017-11-23T15:22:59+00:00

patient handoff at sign-out roundsPatient handoff at sign-out rounds is a high-risk period for clinical oversights and errors. The key to minimize this is to have a clear strategy. This means being precise yet concise, methodical, and forward-thinking in your presentation to the oncoming clinician and team. There are various tools like I-PASS1 to frame your script, but the following are 10 additional key tips to consider.

10 Tips to Minimize Error at Patient Sign-Out Rounds

1. Start with the answer.

This is NOT a murder mystery! Lead with the diagnosis and disposition, if known.

  • NO: “Mrs. Jones in bed 5 has 3 days of fever, periumbilical pain migrating to the RLQ.”
  • YES: “This patient has appendicitis by CT. She’s received appropriate antibiotics, surgery has seen her, she is not pregnant, and her pain is under control. There is nothing to do.”

2. Sign out when you can.

You can never predict when a critically ill patient will arrive, making the oncoming clinician no longer available to take sign-out. Sign out at the designated time. On the receiving end, be ready to take sign-out (even if it is a little early).

3. Start with the sickest or most active patient first.

This is a must. Do not start with someone going home, because they might have left the department by the time you finish sign-out, which increases the likelihood of forgetting something important.

4. Use concise language.

Minimize unnecessary words. More words only add cognitive burden. The more words, the more that may be forgotten.

  • NO: “The first patient that I will tell you about is… actually funny story about him… ”  (all unnecessary).

5. Use precise language.

When describing abnormal values, avoid ambiguity. If it is important enough to mention at sign-out rounds, it requires clarification.

  • NO: The patient has a low blood pressure and elevated lactate.
  • YES: The patient has hypotension with systolics in the 90’s and an initial lactate of 4.6.

6. Include key special information.

For the oncoming clinician, it helps to know if the patient has a unique knowledge base (e.g., is a healthcare provider) or has special needs (e.g., hard of hearing, speaks only Farsi but daughter can translate).

7. Have a disposition in mind.

Is the patient likely to be discharged or being admitted? This does not mean that you have to have arrived at a diagnosis by sign-out rounds, but ideally share your decision-tree plan about disposition and diagnosis. If you are not sure, that is fine. Disclose why you are uncertain and what additional information you need. Be honest.

8. Try not to leave work for others.

You know your patient best. Try not to sign-out unnecessary work. This includes additional diagnostic testing, therapeutics, procedures, and/or consultations, unless both parties agree that this is necessary and to leave the work for the oncoming clinician(s). This also refers to completing discharge instructions in advance (if possible).

9. Be sure to sign out all patients in the department.

This seems intuitive, but this includes even those patients already flagged for discharge. As long as they are in your department, the oncoming clinician/team should be aware in case last-minute problems or patient questions arise.

10. Allow the oncoming clinician/team the chance to ask questions.

This last step allows you to close the loop on any unclear instructions or communications.

Additional Reading

PDF Handout on Handoffs and Consultations from 2012 CORD Academy Assembly Lecture

1.
Starmer A, Spector N, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812. [PubMed]
Gus M. Garmel, MD, FACEP, FAAEM

Gus M. Garmel, MD, FACEP, FAAEM

Clinical Professor (Affiliate) of EM, Stanford University
Senior Emergency Physician, TPMG Kaiser Santa Clara
Senior Editor, The Permanente Journal
Gus M. Garmel, MD, FACEP, FAAEM

Latest posts by Gus M. Garmel, MD, FACEP, FAAEM (see all)

  • Shawn Dowling

    Thank you for this review. Some great pearls in this list and a must read for all ED docs and residents. I’d say point number 2 is a bit controversial and depends on the culture/expectations on the respective ED. In some ED’s the culture is to handover at a designated time whereas in other departments, the expectation is to handover when there is a disposition plan in place.

    • Derek Monette

      I certainly agree, each ED will have its own culture and expectations around sign-out and the optimal time for transferring patient responsibility. I think that the broader point is to be mindful of everyone’s time and the unpredictable nature of our job (which is what makes it so much fun!). Glad you enjoyed the review!

  • Shawn Dowling

    On another note, do you have any experience using a standardized electronic handover tool (like I-PASS)? – see article – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102604/pdf/wjem-17-756.pdf. We are creating this tool in our EMR to improve the handover process. If yes, is it mandatory for all patients or just for complex/sick patients?

  • SAEM EBM IG

    Here’s a clarifying statement that Gus Garmel (who isn’t on Twitter or Facebook) just asked me to post here in response to Shawn Dowling:

    Agree with Shawn
    Dowling that #2 can be a bit controversial related to the culture of the ED.
    That said, dispositions on most patients can be made following a thorough yet
    focused H&P, even before all of the labs or imaging have returned (for
    example, think “what would the dispo be if they were all negative?”).
    One pearl is to try to expedite those tests or imaging that might be needed for
    dispo, so that the patient can be signed over with the key results resulted.
    And signout is a privilege, not simply because a shift has ended. Signout when
    you can, but when dispositions are completed and plans are in place for every
    patient, unless it is not in the best interest of patient safety and patient
    care. You can always “update” your initial signout that occurred at a
    given (scheduled) time, which is a good idea to do before you physically leave
    the ED, but if you wait until you are ready to leave the ED, you might be
    waiting longer than expected because the physician receiving your signout might
    be tied up with a critically ill patient and unavailable. Hope that
    clarifies. Thanks for your comment and interest, Gus