Medical Error Risk Rises Under Shorter Medical Intern Shifts

Cheryl Clark, for HealthLeaders Media , March 26, 2013

Additionally, the 2011 rules resulted in a decrease in "continuity of patient care, intern and nurse perceptions of quality of care, and educational opportunities from teaching and patient care," Desai wrote.

In an accompanying invited commentary, Lara Goitein, MD, and Kenneth M. Ludmerer, MD, of Christus St. Vincent Regional Medical Center in Santa Fe, NM, said the current limitations are "too inflexible."

Not only has the policy change created a situation that leads to increased medical errors, they wrote, but "limiting work hours without commensurately decreasing workload exacerbates the already extreme work compression for residents." In other words, these trainees have to do more in less time.

"Residents still perform most of the work, but are now racing the clock."

Teaching hospitals have focused on work hours, rather than on workload because they "are heavily dependent on the work provided by residents" and reassigning patients to non-resident services "is more expensive than implementing work hour limitations, at least in direct costs.

Goitein and Ludmerer say the situation can be repaired in two ways. First, teaching hospitals can increase resident training positions to reduce work intensity, and they can shift some patients to non-resident providers.

"Of course these measures are costly and will face substantial hurdles," they wrote, but there is some evidence that making adjustments can pay off, and even pay for itself through reduced 30-day readmissions, shorter lengths-of-stay, and reduced need for intensive care unit admission.

In sum, they argue: "Residents should no longer be asked to do an increasing amount of work in less time and with less flexibility."

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2 comments on "Medical Error Risk Rises Under Shorter Medical Intern Shifts"

Steve Spear (4/7/2013 at 7:38 AM)
The key problem is not handoffs per se[INVALID]unless you argue that there should never be a handoff, they will occur[INVALID]it is that the handoff process is poorly designed to preserve hypotheses, data, interpretation, and recommendations one shift to the next. This is not an impossible problem as healthcare is not the only high risk setting (and not even the highest risk of those settings) in which the work progresses with cycle times far beyond human endurance. In other situations[INVALID]Naval nuclear propulsion, space flight, combat outposts, long haul civilian aviation, continuous industrial processes, etc.[INVALID]the handoff problem is well managed. Though risks are high, calamities are rare. The fundamental problem is that healthcare providers (particularly those most senior) continue to view training and treatment solely as expression of individual professional skill rather than recognizing the coordinating routines necessary for success. By the same logic, we would have no ballet or symphonies, only soloists, no relay racers, only individualists, and basketball would look like playground pickup. Steve Spear Sr. Fellow, Institute for Healthcare Improvement Sr. Lecturer MIT

Edward Framer, Ph.D. (3/27/2013 at 6:06 PM)
And there are a lot of us out here who have seen unreasonably long shifts also cause unnecessary injury and death. There is no excuse for 100-120 hour work weeks or for sloppy handoffs.




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