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Sep 15, 2020

Transitions of care are one of the most dangerous activities in medicine. Numerous studies highlight the rates of medical errors which occur at the time of sign-outs. Formalized sign-out processes have been shown to significantly decrease breakdowns in communication and reduce adverse events. In this episode, Dr. Kaminsky sits down with residents from across the country to dissect and discuss different sign-out styles and share some insights regarding bias and areas for improvement.


  • Alex Kaminsky, MD -- UCSF, Fresno


  • Rosemarie Diaz, MD – University of Michigan
  • Mary McLean, MD – St. John's Riverside Hospital
  • Nicholas Robbins, MD – John Peter Smith Hospital

Key Resources:


  • Safer Sign Out Protocol: Available at ACEP.
  • EMRA: Transitions of Care


Key Points:


  • In a prospective multi-center study (>10,000 patients) communication error occurred at a rate pf 24.5 per 100 admissions. Preventable errors were found to be 4.7 per 100 admissions.
  • Effective sign-out strategies have been shown to reduce overall medical errors by ~23% and preventable adverse events by ~30%.


Hand-Off Tools:



Illness severity: Stable, “watcher,” unstable

Patient Summary: HPI, ED course/Ongoing assessment, Plan

Action List: “To-do”

Situation Awareness and Contingency Planning: “If this, then do that.” Give your colleagues an idea of what to do if an event occurs.

Synthesis by Receiver: Person taking the sign out does a “readback” of what they heard. Restate key actions. Also, the time to ask questions.


Situation: Clearly and briefly define the situation

Background: Provide clear, relevant background information that relates to the situation. 

Assessment: A statement of your professional conclusion. 

Recommendation: What do you need from this individual? What to do and contingencies.


S: Sick or not Sick

H: History and Hospital Course 

O: Objective Data 

U: Upcoming plan, disposition

T: To do

 (note: This is by no means a comprehensive list)


  1. Brady P, Gorham J, Kosti A, et al "SHOUT" to improve the quality of care delivered to patients with acute kidney injury at Great Western Hospital. BMJ Open Quality 2015;4:u207938.w3198. doi: 10.1136/bmjquality.u207938.w3198
  2. “SBAR a Powerful Tool to Help Improve Communication.” The Joint Commission, 
  3. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-12.
  4. Heilman JA, Flanigan M, Nelson A, Johnson T, Yarris LM. Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs. West J Emerg Med. 2016;17(6):756-61.
  5. Cheung DS, Kelly JJ, Beach C, Berkeley RP, Bitterman RA, Broida RI, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171-80.