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6 Contributors to Error in the Training Environment
Pages 179-216

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From page 179...
... Because residents are in supervised training programs and work within teams, many mistakes can be intercepted before they can harm patients. Uncertainty surrounds the impact of the 2003 reduction of resident duty hours on patient safety (adverse patient outcomes)
From page 180...
... 4. Would further reductions in resident duty hours improve patient safety?
From page 181...
... Measuring Patient Safety Before beginning, it is important to understand basic terms and approaches used in discussing and measuring patient safety. Defining Medical Errors A spectrum of medical errors may occur during the treatment and care of hospital patients.
From page 182...
... SOURCE: IOM, 2000. for internal hospital quality improvement efforts and for research purposes capture different pieces of data but not a whole picture of patient safety or the universe of error.
From page 183...
... Underreporting appears to be a common problem; such systems may detect fewer than 10 percent of adverse events (Classen et al., 2008; Rothschild et al., 2005) , but the data provided nonetheless can have important uses to the reporting facility when they are embedded in a vigorous error elimination program.
From page 184...
... The committee believes strongly that they can also be of educational value to doctors in training and should become an integral part of residency programs, as discussed in Chapter 8. Determining the Universe of Errors and PAEs with Limited Data As background for the committee's study of the impact of residents' duty hours on patient safety, it would be useful to follow a chain of inquiry and quantify, in order, the universe of medical errors, medical errors made in hospitals, medical errors made by residents, and medical errors made by residents in which fatigue is a contributing factor.
From page 185...
... Assessing Patient Safety and Quality In the absence of a national error-reporting system, several commercial organizations as well as the Centers for Medicare and Medicaid Services (CMS) , the Agency for Healthcare Research and Quality (AHRQ)
From page 186...
... For example, a composite indicator of selected generally avoidable postoperative complications shows that such adverse events occurred in 6.55 percent of cases in 2005, and that nearly one-quarter of surgical patients did not receive appropriately timed antibiotics (AHRQ, 2007)
From page 187...
... , patient safety remains a serious issue in the United States (AHRQ, 2007; Commonwealth Fund, 2008; HHS, 2008)
From page 188...
... Consequently, the magnitude of the impact of residents on patient safety is unknown. FATIGUE AS A CONTRIBUTOR TO ERROR A principal aim of this study is to determine the degree to which resident fatigue from long duty hours poses a significant risk to patient safety and whether there are interventions that might reduce that risk.
From page 189...
... P Bagian, Director, VA National Center for Patient Safety, Department of Veterans Affairs, February 14, 2008.
From page 190...
... . The survey incorporated questions on the relationship of duty hours and fatigue to the quality of care delivered, patient safety, and AEs.
From page 191...
... Overall, the committee concludes that the existing data are insufficient to determine if the current duty hours of residents and the fatigue resulting from them are the most significant causal factors for errors committed by residents or if resident errors occur more frequently than errors committed by other health workers. Assessing Fatigue and Performance After Extended Duty Periods A number of studies have noted poorer performance by residents postcall, but others find no difference.
From page 192...
... (2002a) have confirmed that residents prior to the 2003 duty hour limit were as sleepy before and after extended duty shifts and that their level of sleepiness matched that of persons with clinical sleep disorders.
From page 193...
... IMPACT OF REDUCED DUTY HOURS ON ERROR RATES AND PATIENT SAFETY This section addresses two central questions: (1) Did the 2003 reduction in resident duty hours improve patient safety?
From page 194...
... . In their systematic review of the literature available before implementation of the 2003 ACGME rules, Fletcher and colleagues found few duty hour and patient safety studies that adequately addressed their two criteria: (1)
From page 195...
... Howard and colleagues (2004) found that mortality declined for congestive heart failure, acute myocardial infarction, and pneumonia after New York State's duty hour change, but this could not be attributed with confidence to duty hour reduction alone because mortality rates declined at both teaching and non-teaching hospitals in the state between 1988 and 1991; moreover, the study assigned teaching status to the hospital as a whole rather than to specific patients cared for by residents (Howard et al., 2004)
From page 196...
... compared changes, if any, in patient outcomes at teaching hospitals that should have been affected by the duty hour rule changes versus non-teaching hospitals. They examined a representative national dataset, the HCUP NIS, which is of sufficient size to have enough statistical power to detect changes in mortality.
From page 197...
... The authors conclude that duty hour reforms did not have a positive or negative effect on major patient outcomes and it is possible that the positive and negative effects of reform may have offset each other, that mortality in the ICU environment may not have been sensitive to resident staffing patterns, or that ICUs may have made other compensating changes to maintain and improve patient outcomes (Prasad, 2008)
From page 198...
... . Studies comparing data both before and after the 2003 ACGME limits without control groups may falsely read improvement in error rates or patient outcomes as being related to duty hour reform when in fact they may have nothing to do with resident work hours but reflect national trends toward improved quality of care (Horwitz et al., 2007)
From page 199...
... . Conclusion About Patient Outcomes After Implementation of 80-Hour Duty Week Smaller institution-specific studies allow easier identification of the actual duty hours worked by residents, how fatigued they may be, and the multiple programmatic changes made that help balance the reduction in resident hours (e.g., hire additional staff, remodel their education program, increase attending presence)
From page 200...
... and there may be modest improvements for medical if not surgical patients. Interventional Study -- Reducing Intern Duty Hours in the ICU Setting The most rigorous scientific data on the direct impact of duty hours on patient safety available to the committee comes from three publications that describe overlapping aspects of the same prospective 1-year randomized trial in 2002 and 2003 (Landrigan et al., 2004; Lockley et al., 2004; Rothschild et al., 2005)
From page 201...
... Total duty hours per week were reduced from about 80 to about 60 hours. 2. The duration of long duty periods was reduced from about 30 to about 16 hours.
From page 202...
... . The scientific rigor of the study results and the significance of its findings do not imply that simply changing residents' work schedules along the lines of the authors' intervention schedule would guarantee a similar 36 percent reduction in resident-caused serious medical errors across the spectrum of U.S.
From page 203...
... . • Does the 36 percent reduction in serious medical errors apply to other residency services and to residents in other years of train ing?
From page 204...
... Making a medical error is the first step in a chain of events that can lead to harm to a patient. Errors are precursors of AEs, so reduc tions in errors would appear to hold the promise of improvements in patient safety.
From page 205...
... . Residents see both positive and negative results from the 2003 duty hour reforms with respect to patient safety (Fletcher et al., 2008; Lin et
From page 206...
... In the post-duty hour reform period, similar proportions of residents respond as to what the contributing factors for errors are whether they are in programs that reduced their total weekly work hours (e.g., reduced by 5 or more hours) or made no change in work hours.
From page 207...
... Improving systems (e.g., changing paging practices to decrease interruptions, improved handover procedures, computerized orders to avoid illegible handwriting, better supervision) can improve the performance of residents and improve patient safety (Volpp and Grande, 2003)
From page 208...
... and that it is not just a matter of hours worked or length of shift. Because first-year residents tend to work longer hours than residents in other years, more frequently violate duty hours, and appear to be more vulnerable to making mistakes -- and yet can be reluctant to reach out for help -- the committee has recommended in Chapter 4 the particular need to increase supervision for these trainees.
From page 209...
... 3. Did the 2003 reduction in resident duty hours affect patient safety?
From page 210...
... 4. Would further reductions in resident duty hours improve patient safety?
From page 211...
... Notwithstanding some of the excellent research that has been done in recent years, multi-institutional studies would also have the power to detect changes in preventable adverse errors and mortality as a function of changes in duty hours and any resultant increases in handovers, and would provide data on what kinds of situations need to be targeted to reduce risks to patients and residents. While the research studies discussed in this chapter concerning residents, duty hours, and patient safety generally have limitations and are less conclusive about the effects of duty hours on patient safety, the research discussed in Chapter 7 presents strong evidence that sleep deprivation, which can result from some aspects of current duty hours, can cause fatigue, which contributes to reduced well-being, increased errors, and accidents.
From page 212...
... Hours and Work Schedules to Improve Patient Safety, December 3, 2007, Washington, DC. Classen, D
From page 213...
... 2004. Systematic review: Effects of residents work hours on patient safety.
From page 214...
... 2008. Reporting medical errors to improve patient safety: A survey of physicians in teaching hospitals.
From page 215...
... 2005. The critical care safety study: The incidence and nature of adverse events and serious medical errors in intensive care.
From page 216...
... 2007b. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.


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