Nasca TJ, Day SH, Amis S, et al. N Engl J Med. 2010;363:e3.
This article summarizes the Accreditation Council for Graduate Medical Education's proposed new regulations on housestaff duty hours. The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour weekly limit. Rather than narrowly focusing on duty-hour restrictions, the recommendations take a broad approach to maximizing patient safety in training environments through targeted reductions in work hours for first-year residents, enhanced supervision by attending physicians, standardizing expectations around handoffs and signouts, and engaging residents in safety and quality improvement efforts. Although the current 80-hour work week will be preserved, the new regulations would eliminate extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report). The current regulations, implemented in 2003, have improved residents' quality of life but have not positively impacted patient safety or educational outcomes. The ACGME acknowledged this evidence in crafting recommendations that seek to establish a culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage residents while allowing more autonomy for senior trainees.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-53.
The 2003 regulations that mandated 80-hour work week restrictions have generated significant debate over their impact on patient safety, fatigue, and discontinuity in care. This prospective study examined the role of intern workload and discovered that increased responsibilities were associated with greater sleep loss, longer shift durations, and less participation in educational activities. Investigators also determined that overnight duties during the week and early in the academic year were most problematic, a situation that is likely to worsen in the face of further work hour reductions being proposed. The authors advocate for greater research into workload, concerted efforts to minimize the administrative tasks of trainees, and thoughtful policies that balance patient safety and resident education.
With reductions in resident work hours, a greater number of communication failures have resulted, largely due to an increased number of "sign-outs" between providers. Despite the development of educational curricula, best practice guidelines, and computerized systems for sign-out, the patient care issues that remained around ineffective transfer of information elevated the issue into a National Patient Safety Goal. This prospective audiotape study analyzed more than 500 sign-outs and discovered omission of key information that potentially contributed to delays in diagnosis and treatment from covering providers, near misses, and several inefficiencies or redundancies in work. The authors also reported that failures to provide an accurate overall picture of the patient led to challenges with overnight decision-making. A past AHRQ WebM&M commentary discussed a sign-out–related error and the necessary systems to ensure safe and effective sign-outs.
Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33:19-29.
Efforts to comply with resident work-hour restrictions have placed a significant burden on hospitals and training programs, particularly in addressing the impact of these restrictions on patient safety. This AHRQ-supported study provides a framework to address the scheduling practices that aim to minimize sleep deprivation, optimize teamwork, and promote patient safety. The authors share a number of case examples and discuss policy implications around developing evidence-based scheduling and systematic culture change. This study’s lead author, Dr. Christopher Landrigan, was featured in a past AHRQ WebM&M conversation that discussed the role of sleep deprivation in residency training and its effect on medical errors.
Singh H, Thomas EJ, Petersen LA, et al. Arch Intern Med. 2007;167:2030-6.
This AHRQ-funded study uncovered distinctive features of errors involving trainees, including teamwork and communication breakdowns, failures of supervision and handoffs, and excessive workload. Building on a past study of closed malpractice claims, investigators conducted a subanalysis of those claims in which housestaff or fellows were thought to play an important role. As the claims predate the introduction of trainee work hour restrictions, the authors call for continued research into trainee errors and targeted training interventions to address current areas of concern. An accompanying editorial discusses a dramatically new model for inpatient care that would begin to address the problem areas identified in this study.
Horwitz LI, Kosiborod M, Lin Z, et al. Ann Intern Med. 2007;147:97-103.
The 2003 regulations reducing housestaff duty hours have been controversial. Although some research has shown fewer errors when housestaff worked shorter shifts, many commentators have raised concern about the potential for errors associated with more transfers of care between physicians. This study sought to directly examine the effect of duty hours limitations on clinical outcomes by comparing medical patients hospitalized on a resident service to patients on a non-teaching service before and after duty hour reduction. There was no detectable increase in adverse events among patients cared for by residents, and some outcomes improved (eg, potential medication errors). Another study in the same issue also found reduced inpatient mortality among medical (but not surgical) patients after implementation of duty hour limitations. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Shetty KD, Bhattacharya J. Ann Intern Med. 2007;147:73-80.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours likely improved residents' quality of life, but the effect on patients has been controversial. A prior review did not find evidence linking reduced work hours to improved patient safety. This study analyzed administrative data from 591 community hospitals before and after implementation of duty hours limitations to determine their effect on inpatient mortality. Mortality was reduced among medical patients in teaching hospitals (compared with non-teaching hospitals) after duty hour limitations came into effect, but no such changes were seen in surgical patients. Another study published in the same issue found improvements in some clinical outcomes among medical patients at a single teaching hospital. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-8.
This case study presents the events surrounding the death of a woman admitted to an academic medical center with pancreatitis. The discussion analyzes the sequence of errors that transpired from initial delays in diagnosis and treatment to poor communication and handoffs (the latter is a 2007 National Patient Safety Goal). The authors also explore the common yet unresolved tension in teaching hospitals for attending physicians who must provide appropriate supervision of trainees while also allowing autonomy for growth. This article is the last of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors. An accompanying editorial (available via the link below) by the series editors reflects on the experiences of producing the 13 articles in this collection, the patient safety movement in general, and the importance of sharing these stories as educational tools to drive improvement.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Robins NS. New York NY: Delacorte Press; 1995. ISBN: 9780385308090.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.
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