Ipass sign out11/7/2023 ![]() The critical exchange of information and transfer of patient care responsibility that occurs in handoff is particularly vulnerable to communication errors.( 1) Miscommunications, such as omission of data or transfer of inaccurate information due to inadequate handoff, pose a risk to patient safety and have been linked to sentinel events reported to The Joint Commission.( 1) Increased recognition of medical errors attributable to poor handoff communication stimulated regulatory bodies to broaden their focus to include this important domain. The Commentaryīy Kheyandra Lewis, MD, and Glenn Rosenbluth, MDĮffective communication is essential to the delivery of optimal patient care. After reviewing the incident, the residency program decided that a senior resident should review the written signout and should be present when interns sign out to each other for the first 3 months of the academic year. The sodium management plan had actually been changed, but this was not reflected in the printed written signout.įortunately, the patient did not experience any adverse consequences as a result of the error. On reviewing the written signout, the primary intern realized that he had accidentally printed a copy of the previous day's signout-it had not been updated. A sodium of 144 mmol/L is fine-you shouldn't have done anything." The cross-cover intern was confused and pointed out that she had followed the written signout instructions. The primary team's senior resident expressed surprise when she was told that IV fluids had been started overnight and remarked, "He was getting volume overloaded yesterday, so we didn't want any fluids started unless he was definitely hypernatremic. The following morning, the primary team returned and received signout from the cross-cover intern. The cross-cover intern checked the written signout, which stated "If Na >142 then give 1 liter half normal saline." The cross-cover intern reviewed this plan with her supervising resident, who agreed she then wrote an order to give the IV fluids as instructed. Later that evening, the patient's sodium level test result returned at 144 mmol/L (the upper limit of normal). ![]() The cross-cover intern was already very busy receiving signout from other interns, so she did not specifically review the detailed written instructions with the primary intern. The cross-cover intern asked for more specific directions around managing the patient's sodium, and the primary intern assured her that the necessary information was in the written signout. ![]() He then verbally signed out to the cross-cover intern, asking her to check the patient's sodium level and replete the patient with IV fluids if the sodium was elevated. Before leaving for the day, the primary intern reviewed the overnight plan with his senior resident and attempted to update the signout template in the EHR. However, the primary intern caring for the patient was on his first day of the rotation, as was the night cross-cover intern. At this institution, all housestaff received training in safe handoffs using a standardized, validated tool (I-PASS), and the electronic health record (EHR) had a dedicated signout template. The patient was hospitalized at an academic hospital early in the academic year. He then developed hypernatremia (high blood sodium levels) requiring close monitoring and treatment with IV fluids. During the hospitalization, he experienced significant difficulty swallowing, which resulted in an aspiration pneumonia. ![]() A 75-year-old man was hospitalized due to a stroke.
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