About 98,000 people die every year from medical errors. A recent article in the New York Times describes the recently improved work schedules of medical residents, and how shorter working hours, in combination with other crucial changes in our health care delivery system, can help to reduce medical errors.
In 2003, a policy change required that medical residents work no more than 80 hours per week, cannot provide direct patient care after 24 hours of continued duty, and must get at least one day off per week.
What really spurred this change of rules was the death of 18-year-old Libby Zion, 27 years ago. Within 7 hours of being admitted to the hospital for uncontrollable thrashing and a high fever, Zion was pronounced dead. The patient had been given several different medications, two of which were powerful sedatives to control her body movements. Libby’s father, a writer, learned that his daughter’s doctor had been on duty for almost 24 hours, which he believed contributed to her untimely death. He proceeded to sue the hospital and publicize the situation, prompting a “60 Minutes” episode.
Just last month, a new policy further restricts working hours, abolishing 30-hour overnight shifts for first year residents that have been commonplace in US teaching hospitals. For many years, the medical community has struggled with the issue, with some doctors fighting to preserve long hours for interns because they believe it’s a necessary component to doctor training, and others who believe long shifts cause errors, and are unnecessary because many doctors will go on to practice in the outpatient setting.
Dr. Christopher Landrigan, an associate professor at Harvard Medical School, ran a study published in 2004 that examined the performance of interns in different work schedules, where one group worked the traditional 30-hr every other night schedule, and the other group worked on a staggered schedule, working no more than 16 hours per day. His results were shocking: Interns working the 30 hour traditional schedule made 36% more serious medical errors than the group with more limited, staggered hours.
However, this study was small and uncontrolled, and more large-scale studies that have examined doctor fatigue and medical errors have failed to come to the same conclusions. Most have shown that reduced working hours produced no major improvement in preventing medical errors. These studies lead many believe the core problem is not long hours.
What is it, then? Sleep deprivation seems like an obvious culprit for causing young doctors to make mistakes, but it seems the issue is more complex. One reason may be that as many as 2/3 residents violate the policy, working more than 80 hours per week. Many doctors believe that lack of supervision and reliable computerized records have been overlooked at other possible contributors to medical errors. In addition, shorter shifts may have caused less continuity of care between a patient and their doctor, and when one doctor leaves and another takes over, the patient’s information is often poorly communicated and the handoff becomes a large risk factor for error.
Ted Sectish, a pediatrician who runs the residency program at Children’s Hospital in Boston is committed to improving the handoff process, which he says is not a standardized procedure nor one that is typically taught to students. So far, Sectish’s pilot project which includes computerized patient summaries and a structured verbal handoff has reduced medical errors by almost 40%.
Rather than blame one factor, sleep-deprivation, the article’s author provides some food for thought on how to better understand the underlying structure that allows medical errors to occur: “In 2000, the British psychologist James Reason wrote that medical systems are stacked like slices of Swiss cheese; there are holes in each system, but they don’t usually overlap. An exhausted intern writes the wrong dose of a drug, but an alert pharmacist or nurse catches the mistake. Every now and then, however, all the holes align, leading to a patient’s death or injury.”
So while sleep deprivation may not be the only cause, when lined up with poor supervision, bad handoffs, or insufficient medical records, it undoubtedly plays its part in avoidable errors.
It turns out that Zion died of something known as serotonin syndrome, which was likely brought on by the combination of an antidepressant she had been taking for weeks, and one of the sedatives administered to her in the hospital. A well-rested doctor at the time would have likely made the same mistake. Unfortunately, this mistake would also likely occur in an inpatient setting today, as about 2/3 of US hospitals do not have computerized prescribing systems that alert doctors of such potentially fatal interactions between medications.
What we need is an innovative way of delivering care such that well-rested residents, and all doctors for that matter, have more time to meet with their patients, and that better communication between providers can prevent medical errors. Some simple measures like checklists, electronic medical records/ prescribing systems, and improved communication between health care providers will go a long way toward reducing medical errors. But let’s also let residents catch some Z’s.