Medication Discrepancies during Patient Handoffs: Frequency, Characteristics, and Potential to Harm

1University of Chicago, Chicago, IL
2Pritzker School of Medicine, Chicago, IL
3University of Chicago, Chicago, IL

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 5


Despite increased focus on handoffs, the accuracy of information transferred using resident sign‐outs has not been well characterized. This study aimed to describe the frequency, types, and harm potential of medication discrepancies between patient charts and resident sign‐outs.


All interns and their patients at a single hospital in January 2006 were eligible for this study. For those who consented, daily sign‐outs (Microsoft Word files) from interns were accessed from an electronic archive maintained by the hospital. Daily medication administration records (MARs) were abstracted from patient charts and served as the gold standard. A medication discrepancy was defined as an omission (medication in chart but not on sign‐out) or a commission (medication on sign‐out, but not in chart). To account for any handwritten medication changes (by a covering physician) and therefore not reflected in the archived daily electronic sign‐out, discrepancy rates were calculated after a 24‐hour grace period to account for efforts to update sign‐outs. In addition, discrepancies that were the first time an error was made were recoded as index errors, and the proportion of index errors that persisted on subsequent days was determined. Day of discharge and interns' call days were excluded, as interns may not expend effort to update sign‐outs. Using a modified classification scheme from an earlier study, discrepancies were categorized into 4 levels of potential harm (not harmful, minimal harm, moderate harm, or severe potential to harm).


Of the 247 eligible patients and 10 eligible interns, 186 patients (75%) and 10 interns (100%) participated. Abstracted were 6942 medication entries from the charts of 165 of these patients (89%). After allowing a 24‐hour grace period to update sign‐outs, 1876 entries (27%) contained an omission or commission, of which 80% (1490/1876) were omissions. These discrepancies were traced to 758 index errors, of which 63% (481) persisted past the first day. Omissions were more likely to persist than were commissions (68% [382/580] vs. 53% [99/188], P < .001). More than half the index discrepancies (54%) were potentially harmful (moderate or severe harm). Although omissions were more frequent, commissions were more likely to be severely harmful (38% [72/188] vs. 11% [65/580], P < .0001). Serious omissions were less likely to persist (48% [31/65] vs. 70% [366/523], P < .0001), although there was no association between level of harm of commission and its likelihood of persisting.


Medication discrepancies in sign‐outs are frequent and potentially harmful. Omissions are more frequent and more likely to persist, whereas commissions have a greater harm potential. Although linking sign‐outs to electronic medical records can reduce medication discrepancies, current efforts should also focus on routine updates for all sign‐out data, especially in the many hospitals that do not use sign‐outs linked to the medical record.

Author Disclosure:

V. Arora, None; J. Kao, None; D. Lovinger, None; S. Seiden, None; D. Meltzer, None.

To cite this abstract:

Arora V, Kao J, Lovinger D, Seiden S, Meltzer D. Medication Discrepancies during Patient Handoffs: Frequency, Characteristics, and Potential to Harm. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 5. Journal of Hospital Medicine. 2007; 2 (suppl 2). Accessed May 26, 2019.

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