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Comment
. 2006 Dec;3(12):e487.
doi: 10.1371/journal.pmed.0030487.

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures

Laura K Barger  1 , Najib T Ayas, Brian E Cade, John W Cronin, Bernard Rosner, Frank E Speizer, Charles A Czeisler
Affiliations
Comment

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures

Laura K Barger et al. PLoS Med. 2006 Dec.

Abstract

Background: A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (> or =24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States.

Methods and findings: We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3-3.7) and 7.5 (95% CI, 7.2-7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4-22) and 7.0 (95% CI, 4.3-11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality.

Conclusions: In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education.

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Conflict of interest statement

Competing Interests: BEC is a past consultant for Vanda Pharmaceuticals. CAC, LKB, BR, and FES are paid employees of the Brigham and Women's Hospital, a subsidiary of Partners HealthCare System which employs thousands of interns and residents. CAC has received consulting fees from, or has served as a paid member of, scientific advisory boards for Accelerator, Actelion, the American Physiological Society, Aventis, Avera Pharmaceuticals, Cephalon, Coca-Cola, Hypnion, the NASA Jet Propulsion Laboratory (managed by the California Institute of Technology), the National Center for Sleep Disorders Research (which is part of the National Heart, Lung and Blood Institute), Oxford Biosignals, Pfizer, Morgan Stanley, Sleep Multimedia, the Sleep Research Society (for which CAC has served as president), Respironics, Takeda Pharmaceuticals, Unilever, Vanda Pharmaceuticals, and Warburg-Pincus. CAC owns an equity interest in Hypnion and Vanda Pharmaceuticals. CAC has received lecture fees from the Accreditation Council of Graduate Medical Education (which established the current work-hour standards for interns), the American Academy of Allergy, Asthma and Immunology Program Directors, the Association of University Anesthesiologists, Beth-Israel Deaconess Medical Center, Brown Medical School and affiliated Rhode Island Hospital, Cephalon, Dalhousie University, Harvard University, London Deanery, MPM Capital, Partners HealthCare, Philips Lighting, Sanofi-Aventis, the Smithsonian Institution, Takeda, the Society of Neurological Surgeons, the University of Michigan, the University of Pennsylvania, the University of Pittsburgh, the University of Virginia Medical School, and the University of Wisconsin Medical School. CAC holds a number of process patents in the field of sleep/circadian rhythms (e.g., photic resetting of the human circadian pacemaker), all of which are assigned to the Brigham and Women's Hospital per institutional policy. CAC has also received research prizes with monetary awards from the American Academy of Sleep Medicine, the American Clinical and Climatological Association, the Association for Patient-Oriented Research, the National Institute for Occupational Safety and Health, and the National Sleep Foundation, clinical trial research contracts from Cephalon and Pfizer, an investigator-initiated research grant from Cephalon, and unrestricted research and education funds from Cephalon, Philips Lighting, and the Brigham and Women's Hospital. CAC is the incumbent of an endowed professorship provided to Harvard University by Cephalon. Since 1985, CAC has served as an expert witness on various legal cases related to sleep and/or circadian rhythms, but has never served as an expert witness for a commercial research sponsor or on a matter related to interns or residents.

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