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Journal of General Internal Medicine

, Volume 22, Issue 12, pp 1751–1755 | Cite as

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

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

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 

Notes

Acknowledgments

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.

References

  1. 1.
    Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094–99.PubMedCrossRefGoogle Scholar
  2. 2.
    Arora V, Johnson J, Lovinger D, Humphrey H, Meltzer D. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: Results of a trial of hospitalists. Ann Intern Med. 2002;137(11):866–74.PubMedGoogle Scholar
  4. 4.
    Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med. 2006;144(11):792–8.PubMedGoogle Scholar
  5. 5.
    Franke RH, Kaul JD. The Hawthorne experiments: first statistical interpretation. Am Sociol Rev. 1978;43:623–43.CrossRefGoogle Scholar
  6. 6.
    Cornish P, Knowles S, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547–56.PubMedCrossRefGoogle Scholar
  8. 8.
    Glucose Roller Coaster. AHRQ Web M&M. http://www.webmm.ahrq.gov/case.aspx?caseID=70. Accessed August 27, 2007.
  9. 9.
    Bates DW, Cohen M, Leape LL, et al. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc. 2001;8(4):299–308.PubMedGoogle Scholar
  10. 10.
    Edwards M, Moczygemba J. Reducing medical errors through better documentation. Health Care Manag. 2004;23(4):329–33.Google Scholar
  11. 11.
    Van Eaton EG, Horvath KD, Lober WB, Pellegrini CA. Organizing the transfer of patient care information: the development of a computerized resident sign-out system. Surgery. 2004;136(1):5–13.PubMedCrossRefGoogle Scholar
  12. 12.
    Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200(4):538–45.PubMedCrossRefGoogle Scholar
  13. 13.
    Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197–203.PubMedCrossRefGoogle Scholar
  14. 14.
    Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–55.PubMedGoogle Scholar
  16. 16.
    Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4):257–66.PubMedCrossRefGoogle Scholar

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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