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Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;78:e35-e46.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Axtell AL, Moonsamy P, Melnitchouk S, et al. J Thorac Cardiovasc Surg. 2019.
Physician work hours and fatigue can impact patient safety, particularly among subspecialties focused on high-risk patients. This retrospective cohort study examined outcomes of patients undergoing nonemergent cardiac surgery occurring before or after 3pm. The investigators found no differences in mortality, complications, or length of stay and posit that this may stem from resource availability in these specialized care settings regardless of the time of day.
Dahlke AR, Quinn CM, Chung JW, et al. New Engl J Med. 2017;377:192-194.
The 2011 ACGME resident physician duty hour changes shortened the number of consecutive hours interns could work and mandated more time off between shifts. The FIRST trial randomly assigned general surgery residency programs to the standard duty hour policy or to a more flexible duty hour policy. After one year, the trial demonstrated no difference in patient outcomes, but did show that residents assigned to the more flexible schedule were more likely to perceive a negative impact of duty hours on wellbeing. In this follow-up survey study of surgery residents after year 2 of the trial, researchers found that negative perceptions of wellbeing remained higher among those exposed to the flexible duty hour policy, but concerns about wellbeing had decreased.
Shiralkar U.
Stress, information overload, and high-risk decisions are prevalent in surgery. This book discusses elements of surgical practice that can diminish surgeon performance and contribute to burnout. The author offers recommendations for surgeons to help manage stress levels, including noise reduction, ergonomic considerations, and recognition of fatigue.
Vinden C, Nash DM, Rangrej J, et al. JAMA. 2013;310:1837-41.
Considerable research has shown that sleep deprivation can affect cognitive performance, but the link between fatigue and clinical outcomes, particularly for surgeons, remains unclear. This case-control study sought to determine whether there was an association between sleep deprivation—defined as having performed an emergency procedure the night before—and complication rates for elective laparoscopic cholecystectomy. Although a prior single-institution study found increased complication rates for daytime procedures performed after operating the night before, this study used a much larger population-based database from Ontario, Canada and found no evidence of greater complications in patients whose surgeons had operated the night before. As duty hour restrictions for resident physicians appear to have had no effect on clinical outcomes, this study provides an argument against restricting practicing physician's duty hours.
Minnesota Hospital Association; MHA.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
Ardenne M, Reitnauer PG. Arzneimittel-Forschung. 1975;25:1369-79.
This special issue includes articles exploring systems-oriented safety improvement in surgical care.
Bagian JP. Human Factors and Ergonomics in Manufacturing & Service Industries. 2011;22.
Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.
Chu MWA, Stitt LW, Fox SA, et al. Arch Surg. 2011;146:1080-5.
This prospective study found no additional risk of complications or mortality in cardiac surgery patients when the attending surgeon was sleep deprived (defined as less than 6 hours of sleep the night prior to the procedure). This finding contradicts the results of an earlier study in general surgery patients.
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.
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.
Rothschild JM. JAMA. 2009;302.
Limitations on housestaff duty hours were implemented with the intent of protecting patients by reducing errors made by fatigued residents. Indeed, prior studies have shown that sleep-deprived residents are more prone to committing errors and inadvertently sustaining needlestick injuries. However, comparatively little attention has been paid to the effect of fatigue on attending physicians. Conducted at a single academic medical center, this study evaluated the relationship between sleep deprivation (defined as having operated the night before the scheduled procedure) and complication rates for a range of surgical, obstetric, and gynecologic procedures. There was no overall link between fatigue and complications, but the complication rate was increased for surgeons who had the opportunity to sleep less than 6 hours. Other studies have found that fatigue is influenced by many factors other than hours worked, and therefore further reductions in shift length (as called for in a recent Institute of Medicine report) may not significantly improve patient safety.
Britt LD, Sachdeva AK, Healy GB, et al. Surgery. 2009;146:398-409.
The Institute of Medicine's 2008 report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety recommended further changes to housestaff work hours, including reducing shift length and mandating protected sleep time. This position paper from the American College of Surgeons raises the concern that such changes would compromise the education of surgical trainees, resulting in residents lacking the skill and confidence to enter independent practice. The authors argue against further reductions in duty hours, and call for flexibility in the implementation of new regulations in order to preserve trainees' case volume and overall educational experience.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.