Research shows big risk with residency programs

Young doctors, long work hours, and inexperience are a bad combination when you're trying to improve patient safety, according to new research that provides a clear reminder of the risks inherent in a medical residency program.

Risk managers should not be lulled into a false sense of security by relying the work hour limits enacted in recent years, cautions Carolyn M. Clancy, MD, director of the Health and Human Services Agency for Healthcare Research and Quality (AHRQ). A recent report from her group says nearly 84% of medical interns reported that they are continuing to work hours that exceeded the limits of a 2003 national standard implemented by the medical profession.1

A related study concludes that interns are much more likely to injure themselves mistakenly with a needle or another sharp instrument when working in a hospital more than 20 consecutive hours, or at night.2 The findings build on previous research and the growing awareness that sleep-deprived, first-year doctors in training working traditional 24-hour shifts make many more serious medical errors and crash their cars more often than those whose work is limited to 16 consecutive hours.

Clancy suggests that risk managers should investigate the work hours of any residency program in their organizations and insist that the limits be respected. These studies raise troubling questions about compliance with standards that were developed to reduce medical errors due to work hour-related fatigue," she says. Residency programs that don't comply with these standards could be jeopardizing the safety of both their patients and their interns."

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced work-hour limits for all first-year residents training in U.S. hospitals. Under these standards, interns are limited to a maximum of 30 consecutive work hours (known as the 30-hour rule), which includes time used for sign-out, teaching, and continuity of care. Interns also are prohibited from working more than 80 hours per week (the 80-hour rule), averaged over four weeks, and must be free of all duties for one day in seven (the seven-day rule). In the recent research, an independent, nationwide study conducted by researchers at Brigham and Women's Hospital, Boston, found that 83.6% of interns reported work hours that did not comply with the ACGME standards.

One of the authors of that study, Christopher P. Landrigan, MD, MPH, director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, says the long hours threaten patient safety. He suggests the work hour rules may need to be strengthened even more. Current professional regulations allow doctors-in-training to work 24-30 hours in a row, a limit far beyond established safe limits for pilots and truckers and far beyond the legally enforced 13-hour limit for physicians in Europe," he says. Yet even this permissive limit is routinely exceeded. To address the epidemic of medical errors in this country, we must start by establishing evidence-based, safe work-hour limits for young physicians, and we must then enforce them."

Hours alone don't dictate quality

In the study involving needlestick injuries, researchers found that interns working during the day following an overnight shift suffered 61% more needlesticks and other sharp object injuries than they experienced during a day that was preceded by a night at home (1.3 per 1,000 opportunities vs. 0.76 per 1,000 opportunities). Furthermore, interns suffered more than twice the rate of injuries during the night (1.48 per 1,000) than during the daytime (0.7 per 1,000). Lapses in concentration and fatigue were the two most commonly reported contributing factors (64% and 31%, respectively).

Unfortunately, simply enforcing the work hour limits may not be enough. Research conducted at several medical schools has found that reducing the amount of work hours alone for surgical residents does not appear to improve quality of patient care. A sample of 156 residents from three surgical specialties completed questionnaires designed to measure subjective impressions about the quality of patient care. More than 88% of residents reported that the quality of patient care remained unchanged (63%) or was worse (26%) after work-hour restrictions had been implemented. Overall, residents reported fewer fatigue-related errors following implementation of work-hour restrictions. However, more errors were perceived to be related to continuity of care, miscommunication, and cross-coverage availability.

References

1. Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. JAMA 2006; 296:1,063-1,070.

2. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA 2006; 296:1,055-1,062.

Sources

For more information on residency programs and patient safety, contact:

  • Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD. Phone: (301) 427-1364. E-mail: cclancy@ahrq.gov.
  • Christopher P. Landrigan, MD, MPH, Brigham and Women's Hospital, Sleep Medicine and Pediatrics, Fourth Floor, 221 Longwood Ave., Boston, MA 02115. Phone: (617) 355-2568. E-mail: clandrigan@rics.bwh.harvard.edu.