May 23, 2012 — Fatigue among residents is prevalent, and many are critically impaired during more than a quarter of their time awake, leading to an increase in the risk for medical errors, according to the findings of a new prospective analysis published in the May issue of the Archives of Surgery.
Residents' sleep and awake patterns were continuously recorded via an actigraphy watch for 2 weeks, and mental fatigue was assessed daily by questionnaire. The mean amount of daily sleep was 5.3 hours among all residents. The study found that residents were functioning at less than 80% mental effectiveness during 48% of their time awake and were functioning at less than 70% mental effectiveness during 27% of their awake time. The latter is equivalent to working with a blood alcohol level of 0.08%.
These fatigue levels were predicted to increase the risk for medical errors by 22% compared with well-rested historical control participants. Night-float residents (those who worked from 6 pm to 8 am) were more impaired (P = .02), with an increased risk for medical error of 24% (P = .045) compared with well-rested historical controls while residents who worked day shifts (6 am - 6 pm), had a 19% increased risk for medical errors compared with this same control group.
"A growing body of literature indicates that fatigue may have a substantial role in medical error," write Frank McCormick, MD, from the Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, and colleagues.
"The objective of this study was to apply a novel approach in the clinical setting to measure the incidence and severity of orthopedic surgical resident fatigue and the predicted risk of medical error," note the authors.
Between April 1, 2010, and November 1, 2011, 27 residents at 2 large academic tertiary care centers completed the trial; particular emphasis was given to enrolling residents on rotations involving inpatients, high-risk heavy workloads, and variable schedules. Participants were given a questionnaire addressing demographics, exercise and sleep habits, alcohol, and sedative and stimulant use, as well as sleep or mental health disorders.
The researchers used the SAFTE (sleep, activity, fatigue, and task effectiveness) model to analyze cognitive impairment and the Fatigue Avoidance Scheduling Tool to predict fatigue level during periods of measurement by the actigraphy watch. Using these previously validated tools, researchers were able to determine the total time residents spent functioning at specific fatigue levels. These data were then used to calculate the overall risk for error compared with a well-rested person.
The authors discuss how changes in scheduling may be beneficial in reducing resident fatigue, but that these changes alone are not enough and may not always work. Citing studies of fatigue and fatigue management in high-reliability organizations such as the airline industry and nuclear power plants, the researchers suggest that adopting similar models in residency programs may be considered as a way of reducing the risk for medical errors associated with fatigue.
The authors acknowledge limitations to the study, such as the high number of night-float residents enrolled (which may overestimate fatigue levels) and that medical errors were not directly measured. In addition, only 40% of the entire residency program participated in the study, and therefore it may not be an accurate representation of the residency population.
"Our study describes an effective, feasible, and noninvasive method to study and quantify resident fatigue," write Dr. McCormick and colleagues. "This approach allows for the identification of specific periods, rotations, and individuals that could benefit from targeted interventions and overall risk reduction," they conclude.
Fatigue Is not Alarming, Pervasiveness Is
In an accompanying invited critique, Thomas F. Tracy Jr, MD, from the Division of Pediatric Surgery, Hasbro Children's Hospital, and Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, writes: "[The authors'] actual determination of fatigue during certain periods is not startling, but its pervasiveness is a finding we simply cannot avoid and may have paid lip service to in the past. It is unlikely that the data in this study will be refuted."
He continues, "However, if we are willing to accept these findings, our most important task is to focus on the elusive linkage between fatigue and actual patient harm.... Unfortunately, we have few examples of direct specific correlations from large-scale cause or high-fidelity systems failure analysis that clearly define the fatigue-harm axis across surgical services."
Support for the study was provided by a grant from the Orthopedic Research and Education Foundation, by a departmental grant from an academic enrichment fund, and by hospital grant support from the Center for Quality and Patient Safety. The authors and editorialist have disclosed no relevant financial relationships.
Arch Surg. 2012;147:430-435. Article full text, Critique full text
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