Fatigue, Distress in Internal Medicine Residents Linked to Self-Perceived Medical Errors

Laurie Barclay, MD

September 18, 2010

September 22, 2009 — Fatigue and distress in internal medicine residents are linked to self-perceived medical errors, according to the results of a prospective longitudinal cohort study reported in the September 23/30 issue of the Journal of the American Medical Association.

"Medical errors and patient safety continue to be an important concern for patients and physicians, especially since the Institute of Medicine reported in 1999 that between 48,000 and 98,000 Americans die each year due to preventable adverse events," write Colin P. West, MD, PhD, from the Mayo Clinic in Rochester, Minnesota, and colleagues. "Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown."

The goal of this study was to use validated metrics to examine the association of fatigue and distress with self-perceived major medical errors among categorical and preliminary internal medicine residents who began training from 2003 to 2008 at the Mayo Clinic. Through February 2009, participants completed quarterly surveys including self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the Primary Care Evaluation of Mental Disorders (PRIME-MD) depression screening instrument, and the Epworth Sleepiness Scale.

The primary study endpoint was frequency of self-perceived, self-defined major medical errors. Generalized estimating equations for repeated measures were used to determine associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error.

Of 430 eligible residents, 380 (88.3%) participated, and the mean response rate to individual surveys was 67.5%. Of 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. Subsequent self-reported error was associated with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03 – 1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08 – 1.21; P < .001), based on univariate analyses.

Other factors associated with subsequent error were burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05 – 1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04 – 1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92 – 0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76 – 3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79 – 0.91; P < .001).

When modeled together, fatigue and distress variables remained statistically significant, and there was little change in the point estimates of effect. When sleepiness and distress were modeled together, there also was little change in point estimates of effect. When adjusted for burnout or depression, however, sleepiness was no longer statistically significantly associated with errors.

"This study suggests that fatigue, sleepiness, burnout, depression, and reduced QOL are independently associated with an increased risk of future self-perceived major medical errors," the study authors write.

Limitations of this study include reliance on self-report of medical errors, limited generalizability of these results from a single academic medical center to other training programs, unknown effect of distress or fatigue on retrospective error reporting, and limited power related to the smaller sample size for the Epworth Sleepiness Scale because it was included later in the survey.

"In addition to the national efforts to reduce fatigue and sleepiness, well-designed interventions to prevent, identify, and treat distress among physicians are needed," the study authors conclude. "Additional research is necessary to determine the most effective strategies for accomplishing these goals. Changes to the process of physician training should address both resident fatigue and distress in an effort to improve resident and patient safety."

The Mayo Clinic Department of Medicine Program on Physician Well-Being supported this study. The study authors have disclosed no relevant financial relationships.

JAMA. 2009;302:1294–1300.

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