Table 2

 Response to communication failure during sign-out

Category (n)Sub-category (n)Representative incident
Attempt to resolve uncertainty (9)Unnecessary or repeat work (2)A patient who had a trach got disconnected. I was not even sure why this patient had a trach. We had not discussed it and it was not written down. We 4 belled anesthesia because the trach was pulled out but later I found out that the trach was just for supplemental oxygen and not necessary.” (C6)
Solicit information from others (8)There was a patient who was having pain … and the cross-cover ordered a pain medication and it was written on the sign-out but not discussed. I did not know why it was ordered and then I asked the patient but I felt like I should know that the patient was having back pain.” (P13)