Table 1

 Categories of communication failure in sign-out from preceding shift

Category (n)Sub-category (n)Representative incident (n = 25)*
*More than one category and sub-category mapped to these 25 distinct critical incidents.
Content omissions (22)Active medical problems (9)There was a patient that had hematuria and it was not indicated on the sign-out. They had ordered CBI [continuous bladder irrigation] and I had no idea.” (C3)
Medications or treatments (11)There was a patient who had their heparin drip turned off and it was not mentioned to me that it was turned off.” (P2)
Tests or consults (10)There was a consult that was pending that was not listed and then ID [infectious disease] and pulmonary called with recommendations and there was no note that these recommendations were coming or what I should do with them.” (C2)
Failure-prone communication processes (8)Double sign-out(“night float”) (3)One of my patients – it just said “will need bx”– I did not know where, who recommended it or unclear if I was to schedule this or if it had already had been scheduled. Obviously I needed to know what happened before I went to see my patient so I called the primary intern who was cross covering before the float came on.” (P4)
No face-to-face communication (4)He called me while he was in clinic so it was brief and over the phone and I would have preferred that our sign-out was face to face so I had a chance to ask questions. He had to go to clinic so he just put the sign-out on the wall and then called from there.” (C4)
Illegible or unclear notes (2)The writing from the prior intern was illegible. Later on, I found them and figured out what it meant.” (P3)