Medication discrepancies in resident sign-outs and their potential to harm

J Gen Intern Med. 2007 Dec;22(12):1751-5. doi: 10.1007/s11606-007-0415-x. Epub 2007 Oct 26.


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.

MeSH terms

  • Drug Prescriptions / statistics & numerical data*
  • Humans
  • Internal Medicine
  • Internship and Residency*
  • Interprofessional Relations
  • Medication Errors / statistics & numerical data*
  • Medication Systems, Hospital*
  • Retrospective Studies