For more than 2 decades, since the release of the Institute of Medicine's groundbreaking report To Err is Human: Building a Safer Health System, hospitals and health care systems have struggled to ...understand and improve patient safety. On the basis of 2 large epidemiologic studies, the Institute of Medicine estimated in 1999 that 44,000 to 98,000 patients were being killed each year in the US due to medical errors and called for this rate to be halved within 5 years. The federal government and health systems responded to this call with an increased investment of funding and personnel committed to getting the patient safety epidemic under control. While their collective understanding of the human and systemic drivers of medical errors grew, it became painfully clear that the ambitious goal of halving harms within 5 years was not being achieved.
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.
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In response, accreditation bodies, payers, nonprofit organizations, governments, and hospitals launched major initiatives and invested considerable resources to improve patient safety.
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Some interventions have been shown to reduce errors, such as implementing computerized provider order-entry systems,
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limiting residents' work shifts to 16 consecutive hours,
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and implementing evidence-based care bundles.
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However, many of these interventions have not been evaluated rigorously
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or implemented reliably on a large scale.
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Landrigan presents his views on the report the results of a retrospective cohort study of hospitalizations from 14 US states to evaluate what impact various reductions in public insurance eligibility ...thresholds would have on children. It comments on the article of Bettenhausen et al that shows the current thresholds for public insurance eligibility vary considerably because of underlying state-level variation in the cost of living, the proportion of residents living in poverty, and the prioritization of public health insurance in the political landscape of that state. He pointed out that lowering short-term costs at the expense of our most vulnerable patients is not the answer, it may lie in prevention and addressing poverty.
IMPORTANCE Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. OBJECTIVE To determine whether introduction of ...a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. DESIGN, SETTING, AND PARTICIPANTS Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children’s Hospital. INTERVENTIONS Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. MAIN OUTCOMES AND MEASURES The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. RESULTS Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention. CONCLUSIONS AND RELEVANCE Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.
US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.
Measure continuous pulse oximetry ...use in children with bronchiolitis.
A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.
Hospitalization with bronchiolitis without active supplemental oxygen administration.
The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.
The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.
In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.
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.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
Depression and burnout are highly prevalent among residents, but little is known about modifiable personality variables, such as resilience and stress from uncertainty, that may predispose to these ...conditions. Residents are routinely faced with uncertainty when making medical decisions.
To determine how stress from uncertainty is related to resilience among pediatric residents and whether these attributes are associated with depression and burnout.
We surveyed 86 residents in pediatric residency programs from 4 urban freestanding children's hospitals in North America in 2015. Stress from uncertainty was measured with the use of the Physicians' Reaction to Uncertainty Scale, resilience with the use of the 14-item Resilience Scale, depression with the use of the Harvard National Depression Screening Scale; and burnout with the use of single-item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory.
Fifty out of 86 residents responded to the survey (58.1%). Higher levels of stress from uncertainty correlated with lower resilience (r = −0.60; P < .001). Five residents (10%) met depression criteria and 15 residents (31%) met burnout criteria. Depressed residents had higher mean levels of stress due to uncertainty (51.6 ± 9.1 vs 38.7 ± 6.7; P < .001) and lower mean levels of resilience (56.6 ± 10.7 vs 85.4 ± 8.0; P < .001) compared with residents who were not depressed. Burned out residents also had higher mean levels of stress due to uncertainty (44.0 ± 8.5 vs 38.3 ± 7.1; P = .02) and lower mean levels of resilience (76.7 ± 14.8 vs 85.0 ± 9.77; P = .02) compared with residents who were not burned out.
We found high levels of stress from uncertainty, and low levels of resilience were strongly correlated with depression and burnout. Efforts to enhance tolerance of uncertainty and resilience among residents may provide opportunities to mitigate resident depression and burnout.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, VSZLJ, ZRSKP
Abstract
Light exposure at night impedes sleep and shifts the circadian clock. An extensive body of literature has linked sleep deprivation and circadian misalignment with cardiac disease, cancer, ...mental health disorders, and other chronic illnesses, as well as more immediate risks, such as motor vehicle crashes and occupational injuries. In this issue of the Journal, Zhong et al. (Am J Epidemiol. 2022;191(9):1532–1539) build on this literature, finding that in a cohort of 50,000 California teachers, artificial light at night, noise, green space, and air pollution were all associated with sleep disturbances. Light, noise, air pollution, and the lack of green space are problems inequitably distributed across the population, concentrated among vulnerable populations in inner cities. Zhong et al. provide novel data on the manner in which these local environmental exposures drive sleep deprivation. Future research should explore the degree to which place-based disparities in sleep in turn drive disparities in short and long-term health. Addressing home-based sleep disparities could be an avenue to addressing systemic racism and achieving environmental justice.
IMPORTANCE: While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient ...safety. OBJECTIVE: To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. DESIGN, SETTING, AND PARTICIPANTS: This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. INTERVENTIONS: Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. MAIN OUTCOMES AND MEASURES: The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. RESULTS: Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 55% vs 68 73%; P = .02) and less autonomous (53 72% vs 86 91%; P = .001) with an attending physician present and residents felt less autonomous (11 58% vs 30 97%; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 100% vs 16 80%; P = .04). CONCLUSIONS AND RELEVANCE: Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03318198
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