Simulated Emergency Room Sign-outs: What They Tell Us About Diagnostic Accuracy and Opportunities for Improvement

Emergency department (ED) sign-outs provide continuity of care for patients at shift changes. However, these periods have been associated with communication breakdowns and medical errors. We explored information factors (stage-of-the-case and the explicitness of the sign-out narrative) to determine their impact on clinicians' diagnostic accuracy and confidence.

Clinicians from 2 academic ED sites reviewed patient vignettes sign-out narratives (N=69). Using a within-subjects experiment, the explicitness of the sign-out information (i.e., broad statement about labs versus stating each test) and the patient's stage in the diagnostic process (e.g., labs pending, treatment occurring, etc.) at the time of sign-out varied.

Explicitness (i.e., expansion in description) did not significantly impact diagnostic accuracy (χ2=0.364, df=1, P=0.55) or confidence in the diagnosis (t=0.514, df=273, P=0.61). However, diagnostic accuracy (33%) and confidence in the diagnosis (48.9%) of middle-stage stimuli cases were lower compared with late-stage cases for diagnostic accuracy (60%) (χ2=19.945, df=1, P<0.01) and confidence in the diagnosis (64.1%) (t=5.404, df=273, P<0.01). These effects were found across both trainees and attending physicians, suggesting uncertainty driven by the stage of care impacts decision-making irrespective of experience, site (χ2=0.491, df=1, P=0.48), and clinician role (χ2=0.024, df=2, P=0.99).

The stage of the patient's case affects both clinicians' diagnostic accuracy and confidence in their diagnosis, whereas the explicitness of the information described does not. Patients in the earlier stages of care are most impacted. At sign-out, acknowledging the stage of care the patient is in may provide additional support to clinical decision-making.