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New report recommends strategies to reduce medical resident fatigue-related errors and improve training

Fatigued medical residents need protected sleep periods and increased supervision of work hour limits to improve patient safety and the training environment, according to a new Institute of Medicine (IOM) report funded by the Agency for Healthcare Research and Quality (AHRQ). The report is the result of a 15-month study by an IOM committee that reviewed the relationship between residents' work schedules, their performance, and the quality of care they provide. The study confirms that scientific evidence shows acute and chronically fatigued residents are more likely to make mistakes.

The IOM committee recommends several changes to the existing 80-hour-per-week limit on work hours, including protected sleep periods for residents. The current rules from the Accreditation Council for Graduate Medical Education (ACGME) allow residents to work a maximum 30-hour shift. During this time, they may treat patients for 24 hours and engage in training or transition activities for the other 6 hours. The IOM recommends a change to require residents who complete a 30-hour shift to only treat patients for up to 16 hours. They must then have a 5-hour protected sleep period between 10 p.m. and 8 a.m., during which time other nonsleeping residents or additional staff members could take over patient care.

Other recommendations in the report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (available at http://www.iom.edu/CMS/3809/48553/60449.aspx), include:

• Increased supervision of work hours. Lack of adherence to limits is common and often underreported. The IOM report recommends periodic independent reviews and strengthened protections for residents and others who report a lack of adherence to current work hour restrictions.
• Stronger moonlighting restrictions. Current ACGME rules only count internal moonlighting (additional paid health care work at the same health care facility) against the 80-hour weekly limit. The IOM report recommends internal and external moonlighting count against the 80-hour weekly limit, because moonlighting outside residency training affects strategically designed periods for rest and sleep, which could reduce residents' readiness for their primary duties.
• Guaranteed days off to permit adequate recovery after working long shifts. The IOM committee said residents should receive a 24-hour break from duty each week, with one 48-hour break per month, for a total of 5 days off per month.
• Reasonable on-call periods. The IOM committee said residents should be on call in the hospital no more than every third night.
• Safe transportation provided by hospitals to residents who are too fatigued to drive home. AHRQ-funded research shows that residents more than double their risk of driving accidents when they drive home after working extended shifts.
• Increased resident training on better communication during handovers. Handovers, when clinicians transition care responsibility to other health care providers, are likely to increase with shorter resident shifts. In some cases, multiple handovers could add to the risk for adverse events unless a structured team approach is used.
• Increased involvement of residents in patient safety activities and adverse event reporting. IOM committee members suggest such involvement could greatly increase the resident's educational experience.

Editor's Note: AHRQ has a number of free resources to help residents and other health care providers implement recommendations related to patient safety training and adverse event reporting, including:

• TeamSTEPPS (http://teamstepps.ahrq.gov) was developed by AHRQ and the U.S. Department of Defense. TeamSTEPPS is an evidence-based teamwork system that aims to improve communication among health care professionals through use of a comprehensive set of training curricula.
• Patient Safety Organizations (http://www.pso.ahrq.gov) are new entities with which clinicians and health care providers can work to collect, aggregate, and analyze data—within a legally secure environment of privilege and confidentiality protections—to identify and reduce patient care risks and hazards.
• Patient Safety Culture Surveys (http://www.ahrq.gov/qual/hospculture) are tools that may be used by hospitals, nursing homes, and medical offices to assess their patient safety culture, track changes in patient safety over time, and evaluate the impact of patient safety interventions.
• AHRQ Patient Safety Network (http://www.psnet.ahrq.gov) and AHRQ Morbidity and Mortality Rounds on the Web (http://webmm.ahrq.gov) are Web-based resources, including weekly updates of patient safety literature, research, news, tools, meetings, and an online forum that features expert analysis of medical errors reported anonymously by readers.

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