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PSNet: Patient Safety Network
Journal Article

Medication discrepancies in resident sign-outs and their potential to harm.

Arora V, Kao J, Lovinger D, et al. Journal of general internal medicine. 2007;22:1751-5.

Efforts to standardize hand-offs remain a critical part of preventing communication failures. This study found significant discrepancies when comparing medication lists from patient charts with what was documented in the resident sign-out system. Nearly 30% of chart entries were inconsistent with the sign-out, and the majority of errors were omissions that persisted past the first day. Investigators noted that more than half of the discrepancies were moderately or severely harmful. While the discrepancies were not linked to actual adverse outcomes, the authors advocate for both electronic and automated systems that ensure accuracy in sign-out systems. A past AHRQ WebM&M commentary discussed hand-offs and the need for systems to prevent errors in care transitions.