Table 3

 Categories of failed communication in worst events due to poor sign-out

Category (n)Sub-category (n)Representative description of worst event (n = 21)*
*Four of 21 worst events not represented here.
Content omissions (17)Active medical problem (7)I spent a lot of hours with a bowel ischemia patient who was having pain and bright red blood per rectum. He had a history of clots and I had called surgery, done serial exams, ordered a lactate. Later, the next morning, I found out that these were all useless studies because he had been like that for 3 days.” (P5)
Code status (5)There was a patient who I was cross covering who ended crashing and it was not verbally conveyed or written in the sign-out that the patient was not a full code. The patient was coded for over a minute … we were definitely doing chest compression before someone realized that the patient was not a full code.” (C2)
Baseline status (2)A patient was transferred to the ICU because it appeared that they were worse from the baseline. Of course we did not really know what the baseline was and it turned out that the patient had bad right sided heart failure which would have been helpful to know during the resuscitation as the patient was coding.” (C7)
Rationale of primary team (5)They appeared to be septic and I was unclear why the patient was not on antibiotics and it was not described or communicated on the sign-out why not. I ended up putting the patient on antibiotics but it was a difficult decision since I did not know the reasoning of the primary team.” (P6)