Although patient safety competency development is increasingly a goal of graduate medical education, skills to teach them are lacking. This project report describes the development, implementation, and outcomes of a curriculum developed to meet quality improvement and patient safety educational requirements. The approach included activities such as event reporting, root cause analysis, and disclosure simulation.

Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

This observational study sought to determine whether the ACGME 2011 duty hour reforms led to changes in 30-day mortality or readmissions for several medical diagnoses—acute myocardial infarction, stroke, acute gastrointestinal bleed, or congestive heart failure—and for general, orthopedic, or vascular surgery. The authors examined how hospital teaching status, which they defined using resident-to-bed ratio, affected outcomes for these conditions. This measure provides insight into the intensity of teaching at a given institution rather than defining each hospital as teaching versus nonteaching. During the study time period, although readmissions and mortality both declined overall, this decrease did not differ based on teaching status, suggesting that the improvement in readmissions and 30-day mortality is not attributable to duty hour reform. These results are consistent with prior work following the 2003 duty hour reforms which has failed to demonstrate benefit to patient outcomes from costly duty hour reforms. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.

Although the 2003 duty hour regulations for resident physicians were intended as a patient safety intervention, concerns were raised that the rules might actually result in patient harm by increasing handoffs. These concerns were allayed by prior studies that found no increase in mortality at teaching hospitals after duty hours were restricted. This follow-up study tracked 5-year outcomes among Medicare patients and found no increase in mortality rates at teaching hospitals compared with less teaching-intensive hospitals. While it now appears clear that the 2003 duty hour limits had little impact on either safety outcomes or clinical outcomes, the effect of further regulations implemented in 2011 remains to be seen.

Around-the-clock staffing with faculty intensive care specialists did not improve clinical outcomes in a medical intensive care unit, compared with the traditional staffing model of daytime-only attending physicians.

Seminal studies and widely publicized cases have linked fatigue among trainee physicians with medical errors. In response, the Accreditation Council for Graduate Medical Education (ACGME) has progressively limited duty hours for residents over the past decade. While first-year trainees now may work no more than 16 consecutive hours, upper-level residents may still be on duty for 24 consecutive hours; the ACGME strongly recommends protected sleep time during such extended shifts. Conducted at a single internal medicine residency's two teaching hospitals, this randomized controlled trial found that residents assigned to receive protected sleep time did sleep more and were less fatigued—by subjective and objective measures—compared with residents who had no protected sleep opportunity. However, increased sleep did not translate into improved patient-level clinical outcomes, and extra staffing was required (at one of the two hospitals) to implement the intervention. As prior studies of earlier regulations also did not find improvement in clinical outcomes after duty hour reduction, the relationship between physician work hours and patient safety remains complex and poorly defined.

The safety impact of the ACGME trainee work hour restrictions remains controversial due to contrasting findings that have suggested benefit, harm, and no significant impact. This observational study analyzed all Medicare patients admitted to acute care facilities with a predefined set of primary diagnoses to estimate the 30-day mortality among high-severity medical admissions and the failure to rescue in postoperative surgical admissions. Investigators found no significant harm or benefit to patients with higher-severity illness compared with those with lower risk among both the medical and surgical patients. A past AHRQ WebM&M perspective discussed the impact of fatigue and extended shifts among trainees on the incidence of medical errors.

The 2003 regulations limiting housestaff work hours were implemented in part with the hope that patient outcomes might improve if clinicians were less fatigued. Earlier studies (evaluating medical inpatients at a single hospital, and medical and surgical inpatients at 591 community hospitals) found no evidence of harm to patients, but inconsistent benefits, in the first year after the regulations were implemented. This study examined outcomes after duty hour limitations at Veterans Affairs hospitals for six common medical and surgical diagnoses. Mortality decreased significantly for four common medical diagnoses (but not surgical diagnoses) by the second year after regulations were implemented, and hospitals with larger residency programs saw greater reductions in mortality. However, the authors' companion study of Medicare patients cared for at teaching hospitals did not find any mortality benefit over the same time period. A related editorial discusses the need for more research on the effect of work hour limitations on patient outcomes before additional restrictions are considered.