Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
Brunsberg KA, Landrigan CP, Garcia BM, et al. Acad Med. 2019;94:1150-1156.
Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.
Shapiro DE, Duquette C, Abbott LM, et al. Am J Med. 2019;132:556-563.
Physician burnout is a persistent problem that can have serious effects on safe practice. This review discusses a model to prioritize interventions to address physician burnout. The approach suggests actions at five levels: physical and mental health; safety and security; respect; appreciation and connection; and the ability to fully contribute to care.
Eid SM, Ponor L, Reed DA, et al. J Grad Med Educ. 2019;11:146-155.
Long work hours and fatigue among health care workers can adversely impact patient safety. In 2011, the Accreditation Council for Graduate Medical Education made changes to resident duty hours, but research on the effect of those reforms on resident wellness and patient safety remains somewhat inconclusive. In this retrospective observational study, researchers examined the impact of the 2011 duty hour reforms on patient mortality, length of stay, and cost using data on patients hospitalized in the 2-year periods before and after the work hour changes were implemented. Nonteaching hospitals served as the control group. They found no difference in mortality or length of stay but did find that cost associated with hospitalization decreased slightly at teaching hospitals after the 2011 changes. A past PSNet interview discussed the effect of less restrictive duty hours on patients and residents.
Mossburg SE, Himmelfarb CD. J Patient Saf. 2018;17:e1307-e1319.
Professional burnout is an evolving threat to workforce well-being, health care costs, and patient safety. Leaders of the National Academy of Medicine, Association of American Medical Colleges, and Accreditation Council for Graduate Medical Education recently established a collaborative to promote clinician well-being and resilience. This systematic review explored the relationships between clinician burnout, clinician engagement, organizational safety culture, and patient outcomes. Burnout was consistently associated with self-reported errors. However, when researchers assessed errors objectively, burnout did not reflect an increase in error rates. Few studies have addressed the relationship between burnout and staff engagement or safety culture. An Annual Perspective further explores how to address and prevent health care worker burnout.
Overexposure to clinical alarms can contribute to burnout, errors of omission, and staff fatigue. This guideline suggests improvements for both frontline nurses and nursing leaders to enhance the management of electrocardiogram and pulse oximetry monitoring to reduce false alarms and alarm fatigue.
Clinician burnout can detract from individual wellness, patient safety, and organizational health. This website serves as a companion to a collaborative effort to combat the problem. The site provides research and resources discussing the causes of clinician burnout, its impact on care delivery, and methods available to address factors that contribute to burnout.
Melnyk BM, Orsolini L, Tan A, et al. J Occup Environ Med. 2018;60:126-131.
Burnout and poor staff well-being impede a strong culture of safety. This large cross-sectional study determined that nurses who self-reported a physical or mental illness were more likely to also report involvement in a medical error compared to their healthier peers. In a recent PSNet interview, Linda Aiken discusses the relationship between nursing workforce issues and safety.
Bridgeman PJ, Bridgeman MB, Barone J. Am J Health Syst Pharm. 2018;75:147-152.
Burnout affects the ability of clinicians and trainees to practice safely. This commentary describes work characteristics that contribute to burnout and reviews organizational and educational strategies to reduce professional burnout among pharmacy practitioners and trainees.
Hignett S, Otter ME, Keen C. Int J Nurs Stud. 2016;59:1-14.
Adverse events are thought to be common in patients receiving home health care. This systematic review defined home care safety risks for both patients and caregivers, including awkward working positions, social distractions, abuse and violence, and other issues that are relatively unique to this care setting.
Alarms contribute to distractions, fatigue, and lack of concentration, which can result in patient harm. This commentary examines the problem in ambulatory surgery centers and summarizes resources and recommendations currently available to help staff manage alarms in this setting.
Welp A, Meier LL, Manser T. Front Psychol. 2014;5:1573.
This Swiss study sought to determine the relationship between elements of clinician burnout and mortality, length of stay, and ratings of patient safety. The authors found that clinicians demonstrating symptoms of burnout had lower perceptions of patient safety in the intensive care unit. However, higher levels of burnout among clinicians were not linked to clinical outcomes.
Many health care professionals exhibit symptoms of burnout, and national studies have shown that approximately one-third of practicing physicians and nurses display hallmark symptoms of emotional exhaustion and diminished sense of personal accomplishment. This commentary explores how medical schools, organizational culture, and working while sick can contribute to physician burnout. The author advocates for a systematic bottom-up approach to address the problem.
Shanafelt TD, Boone S, Tan L, et al. Arch Intern Med. 2012;172:1377-85.
Professional burnout—cynicism and a loss of enthusiasm and sense of accomplishment at work—has been shown to be common among both physicians and nurses. This cross-sectional survey of more than 7000 physicians found that burnout among physicians is more common than in the general population, with emergency physicians and primary care physicians the most commonly afflicted. Burnout has been shown to be one of several emotional influences on patient safety; it has also been linked to medical errors and disruptive behavior.
Gallagher AG, Boyle E, Toner P, et al. Arch Surg. 2011;146:419-26.
Unprofessional behavior by clinicians poses definite patient safety threats, but most research in this area has focused on identifying and addressing disruptive behavior in the work environment. This randomized study raises the concern that physician behaviors outside of work can impair work performance. Significant worsening of simulated surgical performance was found when subjects (students and attending physicians) drank alcohol until intoxication the night before performing procedures. The authors of this study recommend that consideration be given to establishing formal recommendations for alcohol consumption prior to operating room duties. Lack of sleep prior to performing surgery has also been associated with surgical complications, and in fact, intoxication and sleep deprivation have been shown to have similar detrimental effects on physicians' cognitive performance.
Fletcher KE, Reed DA, Arora VM. J Gen Intern Med. 2011;26:907-919.
This systematic review of the effect of physician duty hour regulations found that the regulations were associated with improved resident well-being, but had mixed effects on resident educational outcomes and clinical outcomes.
Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.
Shanafelt TD, Balch CM, Bechamps G, et al. Ann Surg. 2010;251:995-1000.
Duty-hour restrictions for resident physicians are intended to improve safety, but research in residents, nurses, and primary care physicians indicates that burnout and depression may be stronger predictors of substandard care than the number of hours worked. This survey of practicing surgeons revealed that 1 in 11 had committed a serious medical error within the past 3 months, and those who had committed an error were much more likely to meet criteria for burnout or depression. As in prior studies of surgeons, work hours were not correlated with likelihood of reporting an error, or being depressed. Although this survey could not determine if surgeons experienced emotional problems because of having committed an error or vice versa, it is well known that clinicians who commit errors experience substantial emotional distress, as discussed in an AHRQ WebM&M commentary.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
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