Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents.

Kathlyn E. Fletcher; Vikas Parekh; Lakshmi Halasyamani; Samuel R. Kaufman; Marilyn M. Schapira; Kristyn Ertl; Sanjay Saint

Study

Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents.

July 2, 2008

Fletcher KE, Parekh V, Halasyamani L, et al. J Hosp Med. 2008;3(3):228-37.

View more articles from the same authors.

Internal medicine residents felt that duty hours regulations had reduced errors related to fatigue, but pressure to adhere to regulations may have increased some types of errors.

PubMed citation

Available at

Related Resources From the Same Author(s)

How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care?

June 4, 2008

Hospitalists as Emerging Leaders in Patient Safety: lessons learned and future directions.

February 25, 2009

Hospitalists as emerging leaders in patient safety: targeting a few to affect many.

August 31, 2005

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

November 1, 2006

Systematic review: effects of resident work hours on patient safety.

September 28, 2005

Effects of work hour reduction on residents' lives: a systematic review.

September 28, 2005

Inpatient housestaff discontinuity of care and patient adverse events.

April 27, 2016

Liability claims and costs before and after implementation of a medical error disclosure program.

August 25, 2010

Identifying patient safety problems during team rounds: an ethnographic study.

July 16, 2014

Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.

January 19, 2011

Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules.

March 23, 2011

Patient safety superheroes in training: using a comic book to teach patient safety to residents.

July 17, 2019

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents.

March 17, 2021

Prevention of ventilator-associated pneumonia: an evidence-based systematic review.

March 27, 2005

Psychological safety and infection prevention practices: results from a national survey.

February 19, 2020

Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting.

January 14, 2009

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce.

July 17, 2013

Hospitalist handoffs: a systematic review and task force recommendations.

September 30, 2009

Clostridium Difficile infection in the United States: a national study assessing preventive practices used and perceptions of practice evidence.

May 20, 2015

Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013.

June 3, 2015

A piece of my mind. Mentorship malpractice.

April 20, 2016

Hiding in plain sight—resurrecting the power of inspecting the patient.

April 26, 2017

Implementing a national strategy for patient safety: lessons from the National Health Service in England.

April 21, 2005

Clinical problem-solving. Lost in transcription.

October 18, 2006

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.

April 28, 2010

Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose.

June 28, 2006

How physicians think: a case-based diagnostic simulation exercise.

September 16, 2020

The influence of hospital leadership support on burnout, psychological safety, and safety climate for US infection preventionists during the coronavirus disease 2019 (COVID-19) pandemic.

September 27, 2023

Targeting zero harm: a stretch goal that risks breaking the spring.

August 12, 2020

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

October 24, 2018

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

June 21, 2023

Controlled trial to improve resident sign-out in a medical intensive care unit.

August 30, 2017

Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009.

December 21, 2011

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

August 21, 2013

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

October 27, 2010

Malpractice claims related to diagnostic errors in the hospital.

August 23, 2017

Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.

December 18, 2013

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

March 6, 2005

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

November 17, 2021

Project BOOST implementation: lessons learned.

September 10, 2014

Electronic alerts to prevent venous thromboembolism among hospitalized patients.

April 15, 2005

Focused ethnography of diagnosis in academic medical centers.

May 9, 2018

Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.

September 19, 2012

Contextual errors and failures in individualizing patient care: a multicenter study.

August 4, 2010

Impact of a computerized physician order-entry system.

June 3, 2009

Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process.

August 14, 2019

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies.

September 5, 2018

The importance of leadership in preventing healthcare–associated infection: results of a multisite qualitative study.

September 15, 2010

How active resisters and organizational constipators affect health care–acquired infection prevention efforts.

April 13, 2011

Introducing the patient safety professional: why, what, who, how, and where?

September 28, 2011

Impact of duty hours restrictions on quality of care and clinical outcomes.

November 21, 2007

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.

November 10, 2010

Effective discharge communication in the emergency department.

February 1, 2012

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

April 14, 2021

Patient safety: threats and solutions.

August 28, 2013

Patient safety: examining the adequacy of the 5 rights of medication administration.

June 30, 2010

What every health lawyer should know about the Patient Safety and Quality Improvement Act of 2005.

April 1, 2020

Medication errors in the outpatient setting: classification and root cause analysis.

March 21, 2007

HomeNet: ensuring patient safety with medical device use in the home.

June 3, 2009

"Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation.

March 6, 2024

Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.

November 5, 2014

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

May 31, 2017

Critical diagnoses (critical values) in anatomic pathology.

August 9, 2006

A program to prevent catheter-associated urinary tract infection in acute care.

June 8, 2016

Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.

April 5, 2017

Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives.

June 22, 2016

Speaking up and sharing information improves trainee neonatal resuscitations.

December 12, 2012

Adolescent use of insulin and patient-controlled analgesia pump technology: a 10-year Food and Drug Administration retrospective study of adverse events.

May 28, 2008

Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions.

August 13, 2014

Improving the quality of health care: who will lead?

March 6, 2005

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

May 6, 2015

Missed steps in the preanesthetic set-up.

April 27, 2011

Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system.

December 17, 2008

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Rates of surgical consultations after emergency department admission in Black and White Medicare patients.

October 26, 2022

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

April 14, 2021

Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.

July 4, 2007

In search of common ground in handoff documentation in an intensive care unit.

May 23, 2012

Driving surgical quality using operative video.

May 25, 2016

The need for organizational change in patient safety initiatives.

August 9, 2006

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.

January 3, 2007

Association of measured quality and future financial performance among hospitals performing cardiac surgery.

December 7, 2022

The Safe Tables Collaborative: a statewide experience.

May 4, 2011

Designing a critical care nurse–led rapid response team using only available resources: 6 years later.

July 9, 2014

The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.

April 22, 2020

A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre.

December 7, 2005

Emergency departments are higher-risk locations for wrong blood in tube errors.

September 29, 2021

Establishing a simulation center for surgical skills: what to do and how to do it.

September 12, 2007

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

Improving self-reported empathy and communication skills through harm in healthcare response training.

January 26, 2022

Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.

October 3, 2018

U.S. adoption of computerized physician order entry systems.

November 30, 2005

Adverse events and hospital-acquired conditions associated with potential low-value care in Medicare beneficiaries.

August 11, 2021

Medical emergency team calls in the radiology department: patient characteristics and outcomes.

March 14, 2012

A novel ICU hand-over tool: the glass door of the patient room.

November 8, 2017

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

July 29, 2009

Negative behaviours in health care: prevalence and strategies.

February 20, 2019

Related Resources

Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study.

February 28, 2024

Public opinion of resident physician work hours in 2022.

November 29, 2023

WebM&M Cases

Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.

August 30, 2023

Systematic review of the impact of physician work schedules on patient safety with meta-analyses of mortality risk.

August 16, 2023

The burden of peri-operative work at night as perceived by anaesthesiologists: an international survey.

June 28, 2023

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.

April 26, 2023

Impact of medical education on patient safety: finding the signal through the noise.

February 8, 2023

Trainee perceptions of resident duty hour restrictions: a qualitative study of online discussion forums.

October 19, 2022

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

May 25, 2022

ACGME 2011 duty hours restrictions and their effects on surgical residency training and patients outcomes: a systematic review.

July 14, 2021

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents.

March 17, 2021

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study.

July 24, 2019

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision.

May 15, 2019

Sleep and alertness in a duty-hour flexibility trial in internal medicine.

March 13, 2019

Patient safety outcomes under flexible and standard resident duty-hour rules.

March 13, 2019

Evaluation of reasons why surgical residents exceeded 2011 duty hour requirements when offered flexibility.

June 20, 2018

Education outcomes from a duty-hour flexibility trial in internal medicine.

March 28, 2018

The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment.

January 31, 2018

Fatigue risk management: the impact of anesthesiology residents' work schedules on job performance and a review of potential countermeasures.

December 13, 2017

Surgical residents' work hours and well-being in year 2 of the FIRST trial.

July 26, 2017

Summary of Proposed Changes to ACGME Common Program Requirements Section VI.

November 23, 2016

Ethical considerations in the development of the Flexibility in Duty Hour Requirements for Surgical Trainees trial.

October 26, 2016

Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care.

October 5, 2016

A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions.

August 24, 2016

The impact of the 2011 Accreditation Council for Graduate Medical Education duty hour reform on quality and safety in trauma care.

April 13, 2016

Early impact of the 2011 ACGME duty hour regulations on surgical outcomes.

January 13, 2016

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial.

March 18, 2015

Understanding the effect of resident duty hour reform: a qualitative study.

August 13, 2014

Inpatient safety outcomes following the 2011 residency work-hour reform.

April 2, 2014

See More About The Topic

Internal Medicine

Fatigue and Sleep Deprivation

Duty Hour Limitation

Residents and Fellows

Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site