Medication Discrepancies in Resident Sign-Outs and Their Potential to Harm
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The accuracy of information transferred during hand-offs is uncertain.
To describe the frequency, types, and harm potential of medication discrepancies in resident-written sign-outs.
Retrospective cohort study.
Internal Medicine interns and their patients at a single hospital in January 2006.
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.
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).
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 WORDSmedication discrepancy sign-out hand-off transition
We are grateful to Ms. Kimberly Alvarez and Mr. Micah Prochaska for their assistance in manuscript preparation and research assistance. We acknowledge funding from the Pritzker Summer Research Program, the Hartford Health Outcomes Research Scholars Program, the Donald W. Reynolds Foundation, and the National Institute of General Medical Sciences. Prior presentations of this work include the Chicago Patient Safety Forum in March 2007, the University of Chicago Medical Education Day in April 2007, and the Society of Hospital Medicine Annual Meeting in Dallas, TX in May 2007.
Conflict of Interest
Dr. Vineet Arora, Julia Kao, Dr. David Lovinger, and Dr. Samuel Seiden have no potential conflicts of interests. Potential conflicts of interest exist with Dr. David Meltzer with the following: National Institute of Health, Centers for Disease Control, Robert Wood Johnson Foundation, Pfizer, Merck, Lilly, Juvenile Diabetes Research Foundation, InHealth, and PeopleChart.