Emergency medicine has evolved from a location, with variably trained and experienced providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus on the diagnosis and care of undifferentiated acute problems.(1) The importance of rapid diagnosis and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has made timeliness not simply a determinant of patient satisfaction but also a significant safety and quality concern—delays in care can be deadly.(2) Emergency physicians (EPs) have identified delays caused by crowding fr
Friesen LD, Vidyarthi AR, Baron RB, et al. J Gen Intern Med. 2008;23:1981-6.
Reducing duty hours for physicians in training should, in theory, improve patient safety by reducing physician fatigue. Indeed, prior research documents a link between increased fatigue and self-reported errors and percutaneous injuries among residents. But do increased work hours directly lead to fatigue? This survey of interns in cognitive specialties (including internal medicine, pediatrics, and psychiatry) at an academic medical center found that the major determinants of fatigue were increased stress level and poorer quality of sleep—not the absolute number of hours worked. Working more than 80 hours per week (the maximum, according to current regulations) was not associated with increased stress or fatigue. This study adds to a growing body of research that questions the relationship between work hours and housestaff fatigue. A recent editorial called for evidence-based duty hours regulations, taking into account not only hours worked per week but overall housestaff workload and other system factors contributing to stress and fatigue.
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.
Ratanawongsa N, Bolen S, Howell EE, et al. J Gen Intern Med. 2006;21:758-63.
The researchers surveyed residents on the impact of duty hour restrictions on professionalism. They found that residents thought it more difficult to incorporate professionalism with the restrictions in place but also thought well-being and teamwork were improved.
This study describes self-reported perceptions of teamwork among operating room and intensive care unit staff as well as those of an airline cockpit crew. In the medical setting, investigators discovered tremendous variation in teamwork perceptions that followed traditional hierarchies. While surgical attendings and residents rated teamwork high, anesthesiology attendings rated it lower, as did surgical nurses and anesthesia residents in decreasing order. The authors also note that discussing errors seems to be a greater challenge in medicine than in aviation, which may derive from the fact that aviation participants acknowledged that fatigue and stress negatively impact job performance. While the findings draw only from survey results and make no connection to actual errors in practice, they do generate support for a safety culture in medicine similar to that of the aviation field.
This review discusses the important role ergonomic and human factors should play in ensuring safe anesthetic care, drawing on literature from non-health care settings. The authors begin by discussing errors in anesthesia and the opportunities created for such errors by the inevitable nature of the job. They continue by presenting a framework for the contributing factors, which include the work environment (eg, noise, lighting, temperature), the human component (eg, team factors, fatigue, workload), and the equipment and system component (eg, alarms, automation). The authors advocate for greater attention to these contributing factors and further study based on the experiences of other high-risk, error-prone industries.
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