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.
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.
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.
Nuckols TK, Escarce JJ. J Gen Intern Med. 2012;27:241-9.
This cost analysis of the 2011 duty hour regulations for resident physicians demonstrates that the regulations will almost certainly result in increased costs for teaching hospitals, unless preventable adverse events decline substantially after the new regulations are implemented.
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.
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.
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
Guralnick S, Rushton J, Bale JF, et al. Pediatrics. 2010;125:786-790.
This position paper responds to the IOM report on resident duty hours and expresses concerns about the impact that further reduction of resident hours could have on trainee competency, the costs of medical education, and the future pediatric workforce.
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
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.
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.
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