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Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;78(6):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.
González-Gil MT, González-Blázquez C, Parro-Moreno AI, et al. Intensive Crit Care Nurs. 2021;62:102966.
The COVID-19 pandemic has resulted in concerns about psychological and emotional well-being of health care professionals. In this cross-sectional study, critical care and emergency nurses in Spain report fears of COVID-19 infection, elevated workloads, higher nurse-to-patient ratios, communication struggles with management, and socio-emotional challenges in caring for their patients and themselves during the pandemic.
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8(8):639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.    
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382(26):2514-2523.
This multicenter cluster randomized trial explored the impact of eliminating extended-duration  work schedules (shifts in excess of 24 hours) on serious medical errors made by residents in the pediatric intensive care unit (ICU). The authors found that residents in ICUs which eliminated extended shifts in favor of day and night shifts of 16 hours or less made significantly more serious errors than residents assigned to extended-duration work schedules. The authors observed that the resident-to-patient ratio was higher during schedules which eliminated extended shifts, but also that these results might have been confounded by concurrent increases in workload in ICUs eliminating extended shifts.
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382(26):2514-2523.
This article presents longitudinal follow-up of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, which examined the effects of flexible duty-hour policies on resident outcomes. After four years, there was no evidence of increased duty-hour violations, decreased satisfaction or decreased well-being among residents randomized to flexible duty-hour policies. The researchers also observed that the beneficial impacts of flexible duty-hours persisted over the four-year period, whereas most of the negative effects diminished over time.
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16(4):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.
Ferguson BA, Lauriski DR, Huecker M, et al. J Emerg Med. 2020;58(3):514-519.
Cognitive errors caused by fatigue can impact patient safety. This study used a brief, electronic cognitive assessment tool to determine the effect of shift work on emergency medicine resident’s alertness. The authors found that alertness is lowest at the end of the evening shift (typically ending between 12:00-2:00am) and there is a significant difference in alertness between the start versus end of the night shift. No significant difference was observed in the day or evening shifts.
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.
Barger LK, Sullivan JP, Blackwell T, et al. Sleep. 2019;42.
In this clustered-randomized trial across six academic medical centers, researchers examined the impact of resident shift duration on hours slept and worked per week during pediatric intensive care unit rotations. They found that residents assigned to extended duration shifts lasting 24 hours or longer worked more hours per week and slept fewer hours per week compared to residents assigned to work shifts lasting 16 hours or shorter.
Persico N, Maltese F, Ferrigno C, et al. Ann Emerg Med. 2018;72(2):171-180.
This study team performed cognitive testing on emergency medicine physicians following nights spent at home versus after 14-hour and 24-hour shifts. They did not find any decrement in performance after a 14-hour shift compared to a night of rest. However, physicians' processing speed, working memory, and perceptual reasoning were worse after a 24-hour shift, suggesting that 24-hour shifts for emergency medicine physicians should be limited.
Blay E, Engelhardt KE, Hewitt B, et al. JAMA Surg. 2018;153:860-862.
This secondary analysis of a prior randomized trial of flexible versus mandated duty hours for trainee physicians examined reasons for staying past the end of a 24-hour call. Most trainees reported voluntarily staying longer, though a significant proportion reported that program, attending, or senior resident expectations to stay longer influenced them. Reports of coercion to remain were less common, and the authors urge programs to ensure that trainees are not being coerced to exceed duty hours.
Ardenne M, Reitnauer PG. Prehosp Emerg Care. 2018;22(Supp 1):9-109.
Health care worker fatigue is a persistent threat to patient safety. Articles in this special issue cover the results of a National Highway Traffic Safety Administration program to explore fatigue among emergency medical service (EMS) providers. The research and guidelines inform efforts to mitigate fatigue in shift workers, with a focus on EMS providers.
Westbrook JI, Raban MZ, Walter SR, et al. BMJ Qual Saf. 2018;27:655-663.
This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.
Wong LR, Flynn-Evans E, Ruskin KJ. Anesth Analg. 2018;126:1340-1348.
Duty hour reductions have been a controversial strategy to address resident fatigue. This commentary discusses guidelines for managing anesthesiology resident work hours and how the limits might affect training. The authors recommend other approaches to address fatigue such as naps, microbreaks, and scheduling and environmental adjustments.
Arzalier-Daret S, Buléon C, Bocca M-L, et al. Anaesth Crit Care Pain Med. 2018;37:161-166.
In this simulation study, trainees performed worse in two simulated patient emergencies when they were sleep deprived compared with their own performance in a rested state, as judged by blinded independent observers. This study adds to evidence supporting duty hour limitations to reduce fatigue among trainee physicians.