The document discusses emergency department handoffs and describes several studies on the topic. It finds that up to 80% of serious medical errors involve miscommunication during handoffs. A 1998 study of 54 malpractice incidents found an average of 8.8 teamwork failures per case, and that better teamwork could reduce errors, improve care quality, and lower litigation risks. A 2007 study of ED malpractice claims found that missed diagnoses, which often involved multiple breakdowns and factors, accounted for 65% of claims and harm including death in some cases. The document advocates for improving ED teamwork and communication to enhance safety.

1. Amber Z Jafferi
Fort-Night Audit ED

2.  Patient Centered
 Team Based
 Risk-Focused
 Physician (Frontline) Developed

3.  S – Sense the error
 A – Act to prevent it
 F – follow Safety Guidelines
 E – Enquire into accidents/deaths
 T – Take appropriate remedial
 Y – Your responsibility

4. … Do No Harm…

6. Variables Adequate Inadequate Not done Wrong entry
Pt. Identification
Name 130 59 1
68% 30.80% 0.52%
MR# 162 27 1
85.20% 14.20% 0.52%
Allergies 156 29 5
82% 15.20% 2.60%
Date 181 9
95.30% 4.70%
Time 156 34
82% 18%
Generic names 102 88
53.60% 46.40%
Dr Identification
Name/Stamp 121 69
63.60% 36.40%
ID 175 15
0.92 0.08

7. Variables Adequate Inadequate Not done
Wrong
entry
Pt. Identification
Name 116 50 1
69% 29.90% 0.60%
MR# 142 24 1
85.00% 14.40% 0.60%
Allergies 142 21 4
85% 12.57% 2.30%
Date 161 6
96.40% 3.60%
Time 141 26
84% 16%
Generic names 97 70
58.00% 42.00%
Dr Identification
Name/Stamp 102 65
61.00% 39.00%
ID 156 11
93.40% 6.60%

8. Variables Adequate Inadequate Not done Wrong entry
Pt.
Identification
Name 14 9
61% 39.20%
MR# 20 3
86.90% 13.10%
Allergies 14 8 1
61% 34.70% 4.30%
Date 20 3
86.90% 13.10%
Time 15 8
65% 35%
Generic names 5 18
21.70% 78.30%
Dr
Identification
Name/Stamp 19 4
82.60% 18.40%
ID 19 4
82.60% 18.40%

10. Variables Adequate Inadequate Not done Wrong entry
Pt. Identification
Name 96 68 3
57.40% 40.70% 1.79%
MR# 95 71 1
56.80% 42.50% 0.59%
Time 78 89
46.70% 53.30%
Past Hx
Med Hx 155 12
92.80% 7.20%
Drug Hx 52 115
31.10% 69.90%
Pain Score
Score 104 63
62.20% 37.80%
Time 84 83
50.30% 49.70%
Post RAT Plan 114 53
68.20% 31.80%
Dr Identification
Name/Stamp 111 56
66.50% 33.50%
ID 135 32
80.80% 32.20%

11.  Used for
 History
 Work up
 SIGN OUT
 HAND OUT

14. Variables Total Adequate Inadequate Not done Wrong entry
Pt. Identification
Name 171 122 49
71.30% 28.70%
MR# 171 160 11
93.50% 6.50%
Physician Name 171 147 24
85.90% 14.10%
Time 171 152 19
88.90% 11.10%
Allergies 171 141 30
82.45% 17.50%
Senior Input 190 141 49
74.20% 25.80%
Discharge
Diagnosis 190 142 48
74.70% 25.30%
Disposition 190 138 52
72.60% 27.40%
Instructions 190 133 57
70% 30%
Sign Out
Name/Stamp 190 121 69
63.60% 36.40%
ID 190 119 71
62.60% 37.40%

15. Variables Total Adequate Inadequate Not done Wrong entry
Pt.
Identification
Name 148 107 41
72.30% 29.70%
MR# 148 143 5
96.60% 3.40%
Physician Name 148 139 9
93.90% 6.10%
Time 148 131 17
88.50% 11.50%
Allergies 148 123 25
83.10% 16.10%
Senior Input 167 126 41
75.50% 24.50%
Discharge
Diagnosis 167 126 41
75.50% 24.50%
Disposition 167 127 40
76.00% 24.00%
Instructions 167 123 44
73.60% 26.40%
Sign Out
Name/Stamp 167 114 53
68.20% 37.80%
ID 167 113 54
67.60% 32.40%

16. Variables Total Adequate Inadequate Not done Wrong entry
Pt.
Identification
Name 23 15 8
65.00% 35.00%
MR# 23 17 6
74.00% 26.00%
Physician
Name 23 8 15
34.70% 65.20%
Time 23 21 2
91.30% 8.70%
Allergies 23 18 5
78.20% 21.80%
Senior Input 23 15 8
65.20% 34.70%
Discharge
Diagnosis 23 16 7
69.50% 30.10%
Disposition 23 9 14
39.13% 60.86%
Instructions 23 10 13
43.50% 56.50%
Sign Out
Name/Stamp 23 7 16
30.40% 69.60%
ID 23 6 17
26% 74%

17. 1. Identify patients correctly
2. Improve effective communication
3. Improve the safety of high alert Medication
4. Ensure correct site, correct procedure Correct Patient
and surgery
5. Reduce the risk of health care associated infections
6. Reduce risk of patient harm resulting from falls

18. Charles “Chaz” Schoenfeld, MD
(1950-2010)

19. • Up to 80% of serious medical errors involve
miscommunication during handoffs
(TJC)
Up to 24% ED malpractice claims related to
handoff
(Cheung 2010)

20. • Production/Time Pressure
• High Noise Levels
• High Acuity
• Multitasking
• Time Sensitive Conditions
• Rapid Turnover
• Frequent Interruptions
• New/Unknown Patients
• Undifferentiated Diagnosis
• Wide Clinical Variation
• Increasing Complexity
ED Factors – Potentiate
Errors

21. • Neglected/Missed Information
• Unclear Transfer of Responsibility
• Team Unaware of Transfer/Issues
• Patient/Family Unaware
• Change in Status
• Lack of Mechanism for QA
Points of Potential Failure

22. High Reliability
High Risk Process + High Risk Environment
Mandates

23. • Structured
• Workable
• Predictable
• Measurable

24. “Hopeful Handoff”

25. • Critical items
conveyed?
• Safeguards?
(Checklist?)
• Current clinical
status?
• Patient
aware/Involved?
• Nurse
aware/involved?
Typical ‘Hopeful’
Handoff

26. • Hope nothing goes wrong
• Safe By Luck or Design?
• Unstructured – No Standard
• Not High Reliability (High Vulnerability)
• Poor Strategy for Safety

27. 1) Record - Critical Data & Pending
Items
2) Review - Form & Computer Data
3) Round – Bedside, Together
4) Relay to the Team – Nurse
Collaboration
5) Receive Feedback – Clinical/QA

28. Check if No Patients Signed Out Off-Going Clinician: _________________ Receiving Clinician: _________________ Date (Shift Started)___________
This form is a Quality Assurance Tool and is NOT part of the medical record
Safer Sign Out Form (v16)
Patient Name & Age Problem List & Key Issues Pending Items Disposition Receiving Clinician’s Notes
Diagnosis/CC:
Key Issues:
Potential Safety Issues or Precautions?
Home__________
_________________________
Admit__________
______________
Transfer________
______________
NH____________
TBD___________
Rounded on Patient
Included/Informed Nurse
Diagnosis/CC:
Key Issues:
Potential Safety Issues or Precautions?
Home__________
_________________________
Admit__________
______________
Transfer________
______________
NH____________
TBD___________
Rounded on Patient
Included/Informed Nurse
Diagnosis/CC:
Key Issues:
Potential Safety Issues or Precautions?
Home__________
_________________________
Admit__________
______________
Transfer________
______________
NH____________
TBD___________
Rounded on Patient
Included/Informed Nurse
Diagnosis/CC:
Key Issues:
Potential Safety Issues or Precautions?
Home__________
_________________________
Admit__________
______________
Transfer________
______________
NH____________
TBD___________
Rounded on Patient
Included/Informed Nurse
Room
Room
Room
Room

29. Safer Sign Out Success
Patientsto Sign Out
It#is#recommended#to#Sign%out%ALL%patients%that%remain%in%the%department#including#admitted#patients#yet#to#have#admission#orders
Key Components
1. Record
• Patient, Critical Details, Follow-upItems
2. Review
· SSO Form & Computer/ chart Data
3. Round Together
• Meet thePatient & AssureaPlan
4. Relay to the Team
• Confirm thePlan with theNurse/ Team
5. Receive Feedback
• UseSSO Form for Clinical Follow-up& ProcessQA
Credits:
The Safer Sign Out processwasoriginally developed by the Safety Leadership Group of Emergency Medicine Associates, PA, PC of Germantown, Maryland
and will be advanced with the following innovation and research partners:
! ! ! ! ! !
(Safer Sign Out Form Back Page)
Best Practices
1) Pre-Round (Off-going clinician)
Informing the patient prior to S.O. may help:
· Better prepare the patient.
· Increase efficiency
· Save your colleague’stime
2) Confirm Mutual Understanding
Complete the sign out with:
“What QuestionsDoYou Have?”
3) Minimize Interruptions
4) Establish a Reliable QA process
· Collect & review forms
· Encourage Peer Coaching

31. • Share the Process
• Teach Others
• Seek Understanding
• Pursue Refinement
• Regionally/Nationally

34. • Voice for Safety in
Emergency Medicine
• National Collaborator
• SSO Flagship Safety
Tool
• Dedicated SSO Website
• Consultation Service

37.  Abstract
 --emergency department care work teams designed
to improve team communication and coordination
and reduce error. The core of this teamwork system
is the teaching of teamwork behaviors and skills,
development of teamwork habits, and creation of
small work teams, all of which are key teamwork
concepts largely drawn from successful aviation
programs. Retrospective study of ED malpractice
incidents. Fifty-four incidents (1985-1996), a sample
of convenience drawn from 8 hospitals, were
identified and judged litigable or preventable by
better teamwork

38.  An average of 8.8 teamwork failures occurred per case.
More than half of the deaths and permanent
disabilities that occurred were judged avoidable. Better
teamwork could save nearly $3.50 per ED patient visit.
Caregivers must improve teamwork skills to reduce
errors, improve care quality, and reduce litigation
risks. [Risser DT, Rice MM, Salisbury ML, Simon R, Jay
GD, Berns SD, The MedTeams Research Consortium:
The potential for improved teamwork to reduce
medical errors in the emergency department.

39.  Presented at the annual meeting of the Society for
Academic Emergency Medicine, Chicago, IL, May
1998, and the American College of Emergency
Physicians Management Academy, New Orleans, LA,
May 1998.
 Daniel T Risser, PhD , Matthew M Rice, MD, JD,
Mary L Salisbury, RN, MSN ∥, Robert Simon, EdD ,
Gregory D Jay, MD, PhD ∥, Scott D Berns, MD,
MPH, The MedTeams Research Consortium

40.  Allen Kachalia, MD, JD, Tejal K. Gandhi, MD, MPH, Ann
Louise Puopolo, BSN, RN, Catherine Yoon, MS, Eric J.
Thomas, MD, MPH, Richard Griffey, MD, MPH, Troyen A.
Brennan, MD, JD, David M. Studdert, LLB, ScD

41.  A total of 79 claims (65%) involved missed ED diagnoses that
harmed patients. Forty-eight percent of these missed diagnoses
were associated with serious harm, and 39% resulted in death.
 The leading breakdowns in the diagnostic process were failure to
order an appropriate diagnostic test (58% of errors), failure to
perform an adequate medical history or physical examination
(42%), incorrect interpretation of a diagnostic test (37%), and
failure to order an appropriate consultation (33%).
 The leading contributing factors to the missed diagnoses were
cognitive factors (96%), patient-related factors (34%), lack of
appropriate supervision (30%), inadequate handoffs (24%), and
excessive workload (23%). The median numbers of process
breakdowns and contributing factors per missed diagnosis were
2 and 3, respectively.

42.  Missed diagnoses in the ED have a complex cause.
They are typically the result of multiple breakdowns in
the diagnostic process and several contributing
factors.

43.  https://www.acep.org/qipssection
 http://www.annemergmed.com/article/S0196-
0644(99)70134-4/
 https://www.acep.org/qipssection/
 http://www.rcem.ac.uk/