By Gary Evans, Medical Writer

The adage that protecting the worker protects the patient is increasingly borne out in studies of burnout and medical errors. In a recently published example, researchers evaluated physician burnout, well-being, and work-unit safety grades in the context of self-reported major medical errors.

In a national survey of physicians, burnout was measured using a questionnaire that assessed levels of depersonalization and emotional exhaustion. Fatigue was measured using a standardized self-assessment questionnaire. Symptoms of depression also were evaluated and respondents were asked this question about suicidal ideation: “During the past 12 months, have you had thoughts of taking your own life?”1

Work unit safety grades were assessed using the traditional A to F scale, and the physicians were asked this question about medical errors: “Are you concerned you have made any major medical errors in the last three months?”

Of 6,586 physicians responding, 54% reported symptoms of burnout, 33% reported excessive fatigue, and 6.5% reported recent suicidal ideation. In addition, 4% reported a poor or failing patient safety grade in their primary work area, and 10.5% reported a major medical error in the prior three months.

“Physicians reporting errors were more likely to have symptoms of burnout (78% vs. 51.5%); fatigue (47% vs. 31%), and recent suicidal ideation (13% vs. 6.5%),” the authors reported.

“In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors,” they concluded. “Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.”

Hospital Employee Health discussed the implications of the findings with lead author Daniel Tawfik, MD, MS, an instructor in pediatric critical care at Stanford University School of Medicine in Palo Alto, CA.

HEH: You conclude that even in units with a strong safety culture, burnout is still independently predictive of medical errors.

Tawfik: We know from prior studies that burnout actually predicts subsequent reporting of errors, and reporting of errors predicts subsequent burnout. It does seem to be a vicious cycle, where one begets the other, and you can end up in a spiral. There has been a prevailing thought that just improving safety practices of individual work units is really all that is needed to reduce medical errors, and by extension break this cycle.

But what we found in this study was that even after adjusting for those safety practices of the work unit, there still was a very strong relationship between burnout and medical errors. That tells us that just trying to improve the safety practices themselves is helpful, but it is not sufficient to truly reduce medical errors.

To really achieve better error reduction we need a multipronged approach that includes improvements to safety practices, but also focuses on individual physicians themselves in reducing their burnout.

HEH: You also found a kind of incremental effect, meaning that medical errors tend to rise along with burnout scores.

Tawfik: This is specifically related to the burnout scales. Often, we categorize people into either they are experiencing burnout or they are not. We tend to dichotomize, and actually much of the paper was analyzed in that way. But we also looked at the burnout scores along these scales.

The measurement of burnout takes place on three different scales, and each scale ranges from 30 to 54 points. We found that even one-point changes on those scales up or down was associated with a change in the likelihood of reporting errors. That suggests to us that it’s not just an issue of experiencing burnout or not — it is actually a continuum. Even moving a little bit along that continuum can make measurable differences.

HEH: Intuitively, one would think that units with lower safety grades would have more medical errors. However, you found a little more granular data on that.

Tawfik: We did find, as hypothesized, that physicians in units with worse safety grades did report more errors. They have three to four times the odds of reporting an error if they are in one of those units with a poor or failing safety grade. But we found that does not explain the whole picture. Even physicians in units with a safety grade of “A,” if they were burned out, had a much higher likelihood of reporting recent errors, versus those in units who were not burned out.

So that tells us that just moving units from a safety grade of “B” to “A” doesn’t reduce as many errors as it could if you were also focused on reducing the burnout in physicians.

HEH: You found that individual wellness factors can be protective, but as they decline burnout appears?

Tawfik: Wellness is a constellation of factors that includes quality of life and the lack of depressive symptoms. In addition to burnout, we looked at markers of well-being. We looked at depressive symptoms, fatigue, suicidality. We found with all of these markers of well-being clinically significant associations between poor well-being and more medical errors. So it is not just burnout itself, but all of these markers of well-being that we looked at that showed similar relationships.

HEH: You found high levels of fatigue in the physicians. Was that in line with the previous research?

Tawfik: That is similar from what we expected from prior studies. In general, it is higher among physicians than in the general population. But that is what we expected. We used that as an adjustment variable to adjust away the fatigue aspects. In the analysis, the relationship we reported for burnout and medical errors was adjusted for the level of fatigue that each physician was having.

Dealing with the resource-demand imbalance is really going to be the most important way to address fatigue. One important contributor to burnout, and likely to fatigue as well, is the excess documentation burden that really has crept into medicine over the last decade or so. Physicians are spending more time documenting what happened with their patients than they are actually spending with the patients themselves.


1. Twafik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic Proceedings. Published online July 9, 2018. DOI: