Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

PLoS Medicine, Dec 2006

Background A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (≥24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. Methods and Findings We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality. Conclusions In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education.

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Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

and attentional failures. PLoS Med 3(12): e487. doi:10.1371/journal. pmed.0030487 Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures Laura K. Barger 0 1 2 Najib T. Ayas 0 1 2 Brian E. Cade 0 1 2 John W. Cronin 0 1 2 Bernard Rosner 0 1 2 Frank E. Speizer 0 1 2 Charles A. Czeisler 0 1 2 0 Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; AHRQ, Agency for Healthcare Research and Quality; CI, confidence interval; NRMP, National Residency Matching Program 1 Academic Editor: Emmanuel Mignot, Stanford University , United States of America 2 1 Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital , Boston , Massachusetts, United States of America, 2 Division of Sleep Medicine, Harvard Medical School , Boston , Massachusetts, United States of America, 3 Sleep Disorders Program, University of British Columbia , Vancouver, British Columbia , Canada , 4 Department of Medicine, Vancouver General Hospital , Vancouver, British Columbia , Canada , 5 Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute , Vancouver, British Columbia , Canada , 6 Channing Laboratory , Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Massachusetts , United States of America A B S T R A C T A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts ( 24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extendedduration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. - In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education. The Editors Summary of this article follows the references. Introduction Although the Accreditation Council for Graduate Medical Education (ACGME) has recently placed limitations on resident work hours in an attempt to reduce fatigue-related medical errors, the practice of working for more than 24 h consecutively remains the cornerstone of American postgraduate medical education. Moreover, a 1999 report from the Institute of Medicine revealed that between 48,000 and 98,000 deaths each year occur due to a medical error [1]. A recent randomized trial reported that interns working extended-duration shifts (defined as at least 24 h continuously at work) had significantly more polysomnographically recorded attentional failures and made significantly more serious medical errors than those scheduled to work shifts 16 h or longer [2,3]. However, that trial was not large enough to determine whether extended-duration work shifts increased the risk of preventable adverse events, for example injury due to a non-intercepted serious error in medical management, although a trend in that direction was reported [3]. To address the impact of extended-duration work shifts on patient safety in a large and more diverse population of interns, we conducted a nationwide study of US interns in which we collected monthly data on self-reported attentional failures (defined as nodding off or falling asleep during patient-care or educational activities), significant medical errors, and preventable adverse events (including fatalities). Details regarding participant recruitment have been described in detail elsewhere [4]. Briefly, in the spring of 2002, we sent email announcements to all individuals who successfully matched to a residency program in the National Residency Matching Program (NRMP) and to all known email addresses of graduating fourth-year medical students of US programs in an effort to reach as many of the 18,447 individuals who matched to residencies via the NRMP. These emails directed potential participants to a secure Web site which provided detailed information about the study and enabled participants to provide electronic informed consent. In June 2002, an email was sent to the 3,429 interns who had volunteered to participate in the study, and they were directed to a password-coded secure Web site to complete a baseline survey that solicited background data. From July 2002 to May 2003, on the 28th day of each month, emails were sent to those who had completed the baseline survey (the study cohort) to direct participants to a secure Web site to complete a monthly survey. Monthly surveys were available on the Web site until the 27th day of the next month, and we ens (...truncated)


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Laura K Barger, Najib T Ayas, Brian E Cade, John W Cronin, Bernard Rosner, Frank E Speizer, Charles A Czeisler. Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures, PLoS Medicine, 2006, 12, DOI: 10.1371/journal.pmed.0030487