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In this retrospective study of 10 hospitals, harms to patients resulting from medical care were common (25 per 100 admissions) and did not decline significantly between 2002 and 2007. In December 1999, the Institute of Medicine (IOM) reported that medical errors cause up to 98,000 deaths and more than 1 million injuries each year in the United States. 1 In response, accreditation bodies, payers, nonprofit organizations, governments, and hospitals launched major initiatives and invested considerable resources to improve patient safety. 2 – 4 Some interventions have been shown to reduce errors, such as implementing computerized provider order-entry systems, 5 , 6 limiting residents' work shifts to 16 consecutive hours, 7 – 9 and implementing evidence-based care bundles. 10 , 11 However, many of these interventions have not been evaluated rigorously 12 or implemented reliably on a large scale. 13 – . . .

Objective To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors.Design Prospective cohort study.Setting Three urban freestanding children’s hospitals in the United States.Participants 123 residents in three paediatric residency programmes.Main outcome measures Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month.Results 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001). Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 0.45 (0.20 to 0.98) compared with 0.53 (0.21 to 1.33, P=0.2).Conclusions Depression and burnout are major problems among residents in paediatrics. Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors.

ObjectiveTo determine whether long weekly work hours and shifts of extended duration (≥24 hours) are associated with adverse patient and physician safety outcomes in more senior resident physicians (postgraduate year 2 and above; PGY2+).DesignNationwide, prospective cohort study.SettingUnited States, conducted over eight academic years (2002-07, 2014-17).Participants4826 PGY2+ resident physicians who completed 38 702 monthly web based reports of their work hours and patient and resident safety outcomes.Main outcome measuresPatient safety outcomes included medical errors, preventable adverse events, and fatal preventable adverse events. Resident physician health and safety outcomes included motor vehicle crashes, near miss crashes, occupational exposures to potentially contaminated blood or other bodily fluids, percutaneous injuries, and attentional failures. Data were analysed with mixed effects regression models that accounted for dependence of repeated measures and controlled for potential confounders.ResultsWorking more than 48 hours per week was associated with an increased risk of self-reported medical errors, preventable adverse events, and fatal preventable adverse events as well as near miss crashes, occupational exposures, percutaneous injuries, and attentional failures (all P<0.001). Working between 60 and 70 hours per week was associated with a more than twice the risk of a medical error (odds ratio 2.36, 95% confidence interval 2.01 to 2.78) and almost three times the risk of preventable adverse events (2.93, 2.04 to 4.23) and fatal preventable adverse events (2.75, 1.23 to 6.12). Working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours was associated with an 84% increased risk of medical errors (1.84, 1.66 to 2.03), a 51% increased risk of preventable adverse events (1.51, 1.20 to 1.90), and an 85% increased risk of fatal preventable adverse events (1.85, 1.05 to 3.26). Similarly, working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours also increased the risk of near miss crashes (1.47, 1.32 to 1.63) and occupational exposures (1.17, 1.02 to 1.33).ConclusionsThese results indicate that exceeding 48 weekly work hours or working shifts of extended duration endangers even experienced (ie, PGY2+) resident physicians and their patients. These data suggest that regulatory bodies in the US and elsewhere should consider lowering weekly work hour limits, as the European Union has done, and eliminating shifts of extended duration to protect the more than 150 000 physicians training in the US and their patients.

Interns made 36 percent more serious errors when working on a traditional schedule than when on an intervention schedule. In a pioneering study published in the Journal 33 years ago, Friedman and colleagues reported that interns made almost twice as many errors reading electrocardiograms after an extended (24 hours or more) work shift than after a night of sleep. 1 More recent studies have similarly found that surgical residents made up to twice the number of technical errors in the performance of simulated laparoscopic surgical skills after working overnight than after a night of sleep. 2 , 3 Although many prior studies have been methodologically limited by the use of nonvalidated self-reports on the timing of sleep and inadequate accounting for circadian . . .

In this study of interns' errors in the ICU, interns made 36 percent more serious errors when working on a traditional schedule (every-third-night call) than when working on a schedule that limited scheduled work to approximately 16 consecutive hours. Most errors were intercepted or did not harm patients. Interns working in ICUs were more attentive during night work when their schedule was modified to reduce work hours. The Accreditation Council for Graduate Medical Education (ACGME) has recently limited work hours for U.S. medical residents to less than 320 hours in a four-week period, with up to 32 additional hours for programs granted exceptions. 1 Largely missing from the debate 2 – 11 are objective data quantifying trainees' actual work and sleep hours. Subjective reports indicated that, before the new regulations were implemented, some trainees worked up to 140 hours per week, 12 – 16 although the validity of such reports has been questioned. 3 , 17 Although residency training may restrict participants' opportunities to sleep, given that there are only 168 hours in a . . .

Background The COVID-19 pandemic resulted in disruptions to medical school training and the transition to residency for new post-graduate year 1 resident-physicians (PGY1s). Therefore, the aim of this study was to understand the perspectives of United States PGY1s regarding the impact of the pandemic on these experiences. Our secondary aims were to understand how desire to practice medicine was impacted by the pandemic and whether PGY1s felt that they were able to meaningfully contribute to the COVID-19 response as students. Method We conducted a national, cross-sectional study of PGY1s who had recently graduated from medical school in 2020. A survey was distributed to PGY1s from across specialties, in programs distributed throughout the United States. It included questions about medical school training during the pandemic, impact on graduation timing and transition to internship, concerns about caring for patients with COVID-19, desire to practice medicine, and ability to meaningfully contribute to the pandemic. Findings are presented using descriptive statistics and univariate logistic regression models. Results 1980 PGY1s consented to participate, 1463 completed the survey (74%), and 713 met criteria for this analysis. 77% of PGY1s reported that the pandemic adversely affected their connection with their medical school communities, and 58% reported that the pandemic impeded their preparation for intern year. 4% of PGY1s reported graduating medical school and practicing as an intern earlier than their expected graduation date. While the majority of PGY1s did not have a change in desire to practice medicine, PGY1s with concerns regarding personal health or medical conditions (OR 4.92 [95% CI 3.20–7.55] p  < 0.0001), the health or medical conditions of others in the home (OR 4.41 [2.87–6.77], p  < 0.0001]), and PGY1s with children (OR 2.37 [1.23–4.58], p  < 0.0001) were more likely to report a decreased desire. Conclusions The COVID pandemic disrupted the social connectedness and educational experiences of a majority of PGY1 residents in a sample of trainees in United States training programs. Those with health concerns and children had particularly challenging experiences. As the current and subsequent classes of PGY1s affected by COVID-19 proceed in their training, ongoing attention should be focused on their training needs, competencies, and well-being.

Background In 2011 the U.S. Accreditation Council for Graduate Medical Education began limiting first year resident physicians (interns) to shifts of ≤16 consecutive hours. Controversy persists regarding the effectiveness of this policy for reducing errors and accidents while promoting education and patient care. Using a mathematical model of the effects of circadian rhythms and length of time awake on objective performance and subjective alertness, we quantitatively compared predictions for traditional intern schedules to those that limit work to ≤ 16 consecutive hours. Methods We simulated two traditional schedules and three novel schedules using the mathematical model. The traditional schedules had extended duration work shifts (≥24 h) with overnight work shifts every second shift (including every third night, Q3) or every third shift (including every fourth night, Q4) night; the novel schedules had two different cross-cover (XC) night team schedules (XC-V1 and XC-V2) and a Rapid Cycle Rotation (RCR) schedule. Predicted objective performance and subjective alertness for each work shift were computed for each individual’s schedule within a team and then combined for the team as a whole. Our primary outcome was the amount of time within a work shift during which a team’s model-predicted objective performance and subjective alertness were lower than that expected after 16 or 24 h of continuous wake in an otherwise rested individual. Results The model predicted fewer hours with poor performance and alertness, especially during night-time work hours, for all three novel schedules than for either the traditional Q3 or Q4 schedules. Conclusions Three proposed schedules that eliminate extended shifts may improve performance and alertness compared with traditional Q3 or Q4 schedules. Predicted times of worse performance and alertness were at night, which is also a time when supervision of trainees is lower. Mathematical modeling provides a quantitative comparison approach with potential to aid residency programs in schedule analysis and redesign.

Communication underlies every stage of the diagnostic process. The Dialog Study aims to characterize the pediatric diagnostic journey, focusing on communication as a source of resilience, in order to ultimately develop and test the efficacy of a structured patient-centered communication intervention in improving outpatient diagnostic safety. In this manuscript, we will describe protocols, data collection instruments, methods, analytic approaches, and theoretical frameworks to be used in to characterize the patient journey in the Dialog Study. Our approach to characterization of the patient journey will attend to patient and structural factors, like race and racism, and language and language access, before developing interventions. Our mixed-methods approach is informed by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework (which describes the sociotechnical system underpinning diagnoses within the broader context of multiple interactions with different care settings over time) and the Safety II framework (which seeks to understand successful and unsuccessful adaptations to ongoing changes in demand and capacity within the healthcare system). We will assess the validity of different methods to detect diagnostic errors along the diagnostic journey. In doing so, we will emphasize the importance of viewing the diagnostic process as the product of communications situated in systems-of-work that are constantly adapting to everyday challenges.

Background In both Europe and the US, resident physician work hour reduction has been a source of controversy within academic medicine. In 2008, the Institute of Medicine (IOM) recommended a reduction in resident physician work hours. We sought to assess the American public perspective on this issue. Methods We conducted a national survey of 1,200 representative members of the public via random digit telephone dialing in order to describe US public opinion on resident physician work hour regulation, particularly with reference to the IOM recommendations. Results Respondents estimated that resident physicians currently work 12.9-h shifts (95% CI 12.5 to 13.3 h) and 58.3-h work weeks (95% CI 57.3 to 59.3 h). They believed the maximum shift duration should be 10.9 h (95% CI 10.6 to 11.3 h) and the maximum work week should be 50 h (95% CI 49.4 to 50.8 h), with 1% approving of shifts lasting >24 h (95% CI 0.6% to 2%). A total of 81% (95% CI 79% to 84%) believed reducing resident physician work hours would be very or somewhat effective in reducing medical errors, and 68% (95% CI 65% to 71%) favored the IOM proposal that resident physicians not work more than 16 h over an alternative IOM proposal permitting 30-h shifts with ≥5 h protected sleep time. In all, 81% believed patients should be informed if a treating resident physician had been working for >24 h and 80% (95% CI 78% to 83%) would then want a different doctor. Conclusions The American public overwhelmingly favors discontinuation of the 30-h shifts without protected sleep routinely worked by US resident physicians and strongly supports implementation of restrictions on resident physician work hours that are as strict, or stricter, than those proposed by the IOM. Strong support exists to restrict resident physicians' work to 16 or fewer consecutive hours, similar to current limits in New Zealand, the UK and the rest of Europe.

To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. Prospective, multicenter before and after intervention study. Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds (\"family centered rounds\"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) 5.2 (3.1 to 8.8), P=0.003). Top box (eg, \"excellent\") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. ClinicalTrials.gov NCT02320175.