Journal of General Internal Medicine

, Volume 22, Issue 12, pp 1751–1755

Medication Discrepancies in Resident Sign-Outs and Their Potential to Harm

  • Vineet Arora
  • Julia Kao
  • David Lovinger
  • Samuel C. Seiden
  • David Meltzer
Hospital Medicine

DOI: 10.1007/s11606-007-0415-x

Cite this article as:
Arora, V., Kao, J., Lovinger, D. et al. J GEN INTERN MED (2007) 22: 1751. doi:10.1007/s11606-007-0415-x

Abstract

BACKGROUND

The accuracy of information transferred during hand-offs is uncertain.

OBJECTIVE

To describe the frequency, types, and harm potential of medication discrepancies in resident-written sign-outs.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Internal Medicine interns and their patients at a single hospital in January 2006.

MEASUREMENTS

Daily written sign-outs were compared to daily medication lists in patient charts (gold standard). Medication discrepancies were labeled omissions (medication in chart, but not on sign-out) or commissions (medication on sign-out, but not in chart). Discrepancies were also classified as index errors (the first time an error was made) and the proportion of index errors that persisted on subsequent days. Using a modified classification scheme, discrepancies were rated as having minimal, moderate, or severe potential to harm.

RESULTS

One hundred eighty-six of 247 (75%) patients and 10 of 10(100%) interns consented. In the 165 (89%) patients’ charts abstracted and compared with the sign-out, there were 1,876 of 6,942 (27%) medication chart entries that were discrepant with the sign-out with 80% (1,490/1,876) labeled omissions. These discrepancies originated from 758 index errors, of which 63% (481) persisted past the first day. Omissions were more likely to persist than commissions (68% [382 of 580] vs 53% [99 of 188], p < .001). Greater than half (54%) of index discrepancies were moderate or severely harmful. Although omissions were more frequent, commissions were more likely to be severely harmful (38% [72 of 188] vs 11% [65 of 580], p < .0001).

CONCLUSIONS

Written sign-outs contain potentially harmful medication discrepancies. Whereas linking sign-outs to electronic medical records can address this problem, current efforts should also emphasize the importance of vigilant updating in the many hospitals without this technology.

KEY WORDS

medication discrepancy sign-out hand-off transition 

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Vineet Arora
    • 1
  • Julia Kao
    • 2
  • David Lovinger
    • 1
  • Samuel C. Seiden
    • 3
  • David Meltzer
    • 1
    • 4
  1. 1.Department of MedicineUniversity of ChicagoChicagoUSA
  2. 2.Pritzker School of MedicineUniversity of ChicagoChicagoUSA
  3. 3.Department of AnesthesiaStanford UniversityPalo AltoUSA
  4. 4.Department of Economics and Harris School of Public Policy StudiesUniversity of ChicagoChicagoUSA

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