The Missing Record of Mental Status in Written Sign-Outs. Issue 4 (December 2019)

• Record Type: Journal Article
• Authors: Croix, Michael; Miller, Donna; Whittle, Jeff; Singh, Siddhartha; Schapira, Marilyn M.; Carnahan, Jennifer; Kuester, Jessica; Kallio, Christa; Framberg, Susan; Fletcher, Kathlyn E.
• Is Part Of: Journal of patient safety. Volume 15:Issue 4(2019)
• Publication Date: 2019-12
• Subjects: transitions in care -- hand offs -- delirium; Patients -- Safety measures -- Periodicals; Medicine -- Practice -- Safety measures -- Periodicals; Medical errors -- Prevention -- Periodicals; 610.289
• DOI: 10.1097/PTS.0000000000000280
• Languages: English
• ISSNs: 1549-8417

Abstract

Abstract : Objective: The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians. Patients and Methods: This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out. Results: Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs. Conclusions: Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.