Reducing error in the emergency department: A call for standardization of the sign-out process

Annals of Emergency Medicine

Volumn 56, Issue 6, 2010, Pages 637-642

  Dhingra, Kapil R ^a   Elms, Andrew ^a   Hobgood, Cherri ^b  

^a UNIVERSITY OF CALIFORNIA   (United States)

^b UNIVERSITY OF NORTH CAROLINA SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL EFFECTIVENESS; EMERGENCY WARD; INTENSIVE CARE UNIT; INTERPERSONAL COMMUNICATION; MEDICAL EDUCATION; MEDICAL ERROR; MEDICAL HISTORY; MEDICAL INFORMATION SYSTEM; PATIENT SAFETY; PRIORITY JOURNAL; REVIEW; STANDARDIZATION; TEAM BUILDING;

COMMUNICATION; EMERGENCY MEDICINE; EMERGENCY SERVICE, HOSPITAL; HUMANS; INTERNSHIP AND RESIDENCY; MEDICAL ERRORS; PATIENT CARE TEAM; PATIENT DISCHARGE;

EID: 78649503801     PISSN: 01960644     EISSN: 10976760     Source Type: Journal    
DOI: 10.1016/j.annemergmed.2010.02.004     Document Type: Review

References (42)

1. Institute of Medicine To Err Is Human 2000 National Academy Press Washington, DC
2. D.M. Gaba, and S.K. Howard Patient safety: fatigue among clinicians and the safety of patients N Engl J Med 347 2002 1249 1255
3. V. Arora, J. Johnson, and D. Lovinger Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis Qual Saf Health Care 14 2005 401 407
4. Joint Commission on Accreditation of Health Care Organizations Sentinel event statistics [announcement] Joint Commission on Accreditation of Health Care Organizations Web site http://www.jointcommission.org/SentinelEvents/Statistics March 31, 2003 Accessed August 7, 2006
5. P. Croskerry, and D. Sinclair Emergency medicine: a practice prone to error CJEM 3 2001 271 276
6. L.I. Horwitz, T. Meredith, and J.D. Schurr Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care Ann Emerg Med 53 2009 701 710
7. D.S. Cheung, J.J. Kelly, and C. Beach Improving handoffs in the emergency department Ann Emerg Med 55 2010 171 180
8. Joint Commission on Accreditation of Health Care Organizations National Patient Safety Goals Joint Commission on Accreditation of Health Care Organizations Web site http://www.jointcommission.org/NR/rdonlyres/31666E86- E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP-NPSG.pdf 2008 Accessed March 3, 2010
9. Joint Commission Resources Hand-off Communication National Patient Safety Goal http://www.jointcommission.org/AccreditationPrograms/HomeCare/Standards/ 09-FAQs/NPSG/Communication/NPSG.02.05.01/hand-off-communications.htm Accessed March 2, 2010
10. E.G. Van Eaton, K.D. Horvath, and W.B. Lober 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 200 2005 538 545
11. V. Arora, and J. Johnson A model for building a standardized hand-off protocol [review] Jt Comm J Qual Patient Saf 32 2006 646 655
12. B. McFetridge, M. Gillespie, and D. Goode An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit Nurs Crit Care 12 2007 261 269
13. E.E. Sullivan Hand-off communication J Perianesth Nurs 22 2007 275 279
14. J.I. Singer, and J. Dean Emergency physician intershift handovers: an analysis of our transitional care Pediatr Emerg Care 22 2006 751 754
15. R.L. Helmreich, A.C. Merritt, and J.A. Wilhelm The evolution of crew resource management training in commercial aviation Int J Aviat Psychol 9 1999 19 32
16. D.M. Gaba Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience Simulation Gaming 32 2001 175 193
17. M. Sinha, J. Shriki, and R. Salness Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors Acad Emerg Med 14 2007 192 196
18. K.G. Volpp, and D. Grande Resident's suggestions for reducing error in teaching hospitals N Engl J Med 348 2003 851 855
19. J.G. Adams, and J.S. Bohan System contributions to error Acad Emerg Med 7 2000 1189 1193
20. R. Behara, R.L. Wears, and S.J. Perry Conceptual framework for the safety of handovers K. Henriksen, Advances in Patient Safety 2005 Agency for Healthcare Research and Quality/Department of Defense Rockville, MD 309 321
21. M. Brandwitk, C. Nemeth, and M. O'Connor Distributing cognition: ICU handoffs conform to Grice's maxims http://www.ctlab.org/documents/SCCMPoster1. 27.03.pdf Accessed March 2, 2010
22. D.M. Berwick SBAR technique for communication: a situation-briefing model Institute of Health Care Improvement Web site http://www.ihi.org/IHI/Topics/ PatientSafety/SafetyGeneral/Tools/ SBARTechniqueforCommunicationASituationalBriefingModel.htm Accessed January 23, 2009
23. L. Woodhall, L. Vertacnik, and M. McLaughlin Implementation of SBAR communication technique in a tertiary center J Emerg Nurs 34 2008 314 317
24. V. Marini The SBAR technique: improves communication, enhances patient safety Jt Comm Perspect Patient Saf 5 2005 1 2 8
25. SBAR initiative to improve staff communication Healthcare Benchmarks Qual Improv 12 2005 40 41
26. E. Salas, C.A. Bowers, and J.A. Cannon-Bowers Military team research: 10 years of progress Mil Psychol 7 1995 55 75
27. S.C. Hu, D.H. Yen, and W.F. Kao The feasibility of full computerization in the ED Am J Emerg Med 20 2002 118 121
28. S.J. Henkind, and J.C. Sinnett Patient care, square-rigger sailing, and safety JAMA 300 2008 1691 1693
29. E.S. Patterson, E.M. Roth, and D.D. Woods Handoff strategies in settings with high consequences for failure: lessons for health care operations Int J Qual Health Care 16 2004 125 132
30. L.A. Petersen, E.J. Orav, and J.M. Teich Using computerized sign-out program to improve continuity of inpatient care and prevent adverse events Jt Comm J Qual Improv 24 1998 77 87
31. A. Gawande The checklist New Yorker 10 2007 86 101
32. P. Pronovost, D. Needham, and S. Berenholtz An intervention to decrease catheter-related bloodstream infections in the ICU N Engl J Med 355 2006 2725 2732
33. A.B. Haynes, T.G. Weiser, and W.R. Berry A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 360 2009 491 499
34. I. Philibert, and D.C. Leach Re-framing continuity of care for this century Qual Saf Health Care 14 2005 394 396
35. E.S. Patterson, and D.D. Woods Shift changes, updates, and the on-call model in space shuttle mission control Computer supported cooperative work J Collab Comput 10 2001 317 346
36. A. Laxmisan, F. Hakimzada, and O.R. Sayan The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care Int J Med Inform 76 2007 801 811
37. D.P. Baker, E. Salas, and H. King The role of teamwork in the professional education of physicians: current status and assessment recommendations Jt Comm J Qual Patient Saf 31 2005 185 202
38. D.T. Risser, M.M. Rice, and M.L. Salisbury The potential for improved teamwork to reduce medical errors in the emergency department The MedTeams Research Consortium Ann Emerg Med 34 1999 373 383
39. F.C. Spencer Human error in hospitals and industrial accidents: current concepts J Am Coll Surg 191 2000 410 418
40. EM Model Review Task Force The Model of the Clinical Practice of Emergency Medicine 2007 EM Residency Review Committee East Lansing, MI
41. Accreditation Council for Graduate Medical Education Common program requirements: general competencies Accreditation Council for Graduate Medical Education Web site http://www.acgme.org/outcome/comp/ GeneralCompetenciesStandards21307.pdf Accessed January 23, 2009
42. E.S. Patterson Structuring flexibility: the potential good, bad, and ugly in standardization of handovers Qual Saf Health Care 17 2008 4 5