VA QI Morning Report: Signout Safety

This morning at the VA Quality Improvement Morning Report we discussed signout safety by using the illustrative case found here.

In this case, a patient received inappropriate full-dose anticoagulation instead of the intended DVT prophylaxis dosing of heparin. The authors described that ambiguous signout/handoff was the culprit.  Specifically, the lack of descriptive contingencies regarding exact dosing of the intended medication and route of administration contributed greatly to the outcome.

The Joint  Commission in 2016 identified that nearly 50% of all sentinel events reported to them involved handoff failures. As a result, improving the handoff process is a leading patient safety goal. However, several barriers exist that add difficulty to the handoff process, including the increasing complexity of hospitalized patients, work restrictions, and increasing frequency of handoffs. Improving the handoff process is both of incredible importance, and enormous difficulty.

Starmer and colleagues published a successful study in JAMA in 2013 describing their results after implementing a handoff “bundle”.  The bundle consisted of an initial 2 hour training session, introduction of the SIGNOUT? mnemonic, and restructuring the institution signout to be a unified team handoff. Handoffs were occasionally supervised and a computerized tool automatically imported patient information, leaving the “Summary”, “To-Do”, and “Contingency” as the only free-form sections.

The authors tracked medical errors for 3 months prior to the intervention and 3 months after the intervention and found a significant decrease in the total number of errors from 33.8 per 100 admissions to 18.3 per 100 admissions.


  1. Handoff is a risky period. Taking the time to ensure signout is clear and thoughtful is something we all owe to our patients.
  2. Finding the appropriate level of detail to include in the signout takes experience, but erring on too much detail is better than not enough
  3. Standardized handoff method such as SIGNOUT? or I-PASS appear to reduce erros
  4. The electronic medical record and computer can help you, but cannot replace you.


JAMA. 2013;310(21):2262-2270. doi:10.1001/jama.2013.281961