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) |