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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.
Parshuram CS, Amaral ACKB, Ferguson ND, et al. CMAJ. 2015;187:321-9.
This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.
Moonesinghe SR, Lowery J, Shahi N, et al. BMJ. 2011;342:d1580.
Duty hours for resident physicians in the United States have been limited to 80 hours per week since 2003, but more stringent European regulations now limit trainees to 48 hours on duty each week. This systematic review concurred with another recent review in finding that the American regulations have not negatively impacted trainee or patient outcomes, but found that the impact of European regulations has not been adequately studied.
Levine AC, Adusumilli J, Landrigan CP. Sleep. 2010;33:1043-53.
The most controversial aspect of the Accreditation Council for Graduate Medical Education's 2010 proposed regulations for resident physician work hours may be the elimination of traditional 24-hour shifts for first-year residents. This systematic review summarizes the existing evidence on eliminating these extended-duration shifts and finds that most studies reported improvements in resident education and quality of life, along with preserved or improved patient safety outcomes. However, all included studies were relatively small and conducted at single hospitals, and many had other important methodological limitations. A recent survey of residency program directors found that implementation of the proposed 16-hour shift limit will be challenging, as most programs do not currently adhere to this regulation.
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.
Nuckols TK, Bhattacharya J, Wolman DM, et al. N Engl J Med. 2009;360:2202-15.
A recent Institute of Medicine (IOM) report recommended significant changes to resident physicians' work hours to improve patient safety. These recommendations included eliminating extended duration shifts or scheduling nap times during extended shifts, decreasing resident workload, and strictly adhering to the 80-hour weekly work limits originally implemented in 2003. The implementation of the IOM recommendations would cost teaching hospitals approximately $1.6 billion, according to this analysis. However, due to a lack of clear evidence on the safety effects of duty-hour reduction, the authors were unable to accurately estimate the cost savings to society if adverse events were reduced. The accompanying editorial notes the relative lack of evidence supporting additional duty-hour reductions and calls for further study of the relationship between duty hours, handoffs, and patient safety.
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.
Volpp KG, Landrigan CP. JAMA. 2008;300:1197-9.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours have generated an expansive field of research into their impact on fatigue, workload, clinical outcomes, and patient safety. This commentary aims to put the current research into a practical context and provides eight priorities that should guide teaching institutions in their efforts to balance both physician and patient safety. The authors highlight alternative staffing models (e.g., no more 24-hour shifts), improved sign-out procedures, greater monitoring and evaluation of duty hour changes, the importance of adequate supervision and workload intensity, and better designed financial incentives to promote successful policy change. The Agency for Healthcare Research and Quality (AHRQ) has sponsored an Institute of Medicine (IOM) committee to review the important research and related issues around work hour restrictions.
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.
Bhavsar J, Montgomery D, Li J, et al. Am J Med. 2007;120:968-74.
Research into the effects of residency work hour restrictions on patient safety has yielded mixed results in the surgical, medical, and intensive care settings. This retrospective analysis of patients admitted with an acute coronary syndrome—both before and after work hour restrictions had gone into effect—demonstrated improvements in the quality and efficiency of care with no adverse impact on patient outcomes. While the authors point out that a concurrent quality improvement program was also implemented during the study period, they call for greater research into the structural and process factors that may contribute to improved outcomes.
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.