Closer Resident Supervision Does Not Reduce Medical Errors

Troy Brown, RN

June 05, 2018

Having attending physicians participate on work rounds does not reduce the rate of medical errors made by medical residents in a large academic hospital, new data show.

In fact, the "data suggest that a larger attending physician presence may have negative consequences for resident education because interns spoke less and residents felt less empowered to make independent medical decisions," the researchers write.

Kathleen M. Finn, MD, from the Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, and colleagues report their findings in an article published online June 4 in JAMA Internal Medicine.

The researchers conducted a 9-month randomized clinical trial on an inpatient general medical service of a large academic medical center from September 30, 2015, to June 22, 2016. They designed the timing of the study to avoid the summer months, when new residents start their residency.

The investigators assigned 22 clinical teaching attending physicians to provide increased direct supervision during which they participated on work rounds of previously admitted patients, or to provide standard supervision during which they were available to residents and participated in bedside presentations of newly admitted patients, but not work rounds. Attending physicians provided increased supervision for a 12-week block and standard supervision for a 12-week block, in random order.

Preventable Medical Errors, Near Misses Did Not Differ Significantly

The overall rate of medical errors, which was the primary study endpoint, did not differ significantly between the groups, at 107.6 per 1000 patient-days in the standard supervision group vs 91.1 per 1000 patient-days in the increased supervision group (15% relative reduction; 95% confidence interval [CI], −36% to 9%; P = .21).

Similarly, preventable adverse events (80.0 vs 70.9 events per 1000 patient-days; P = .36) and rate of near misses (27.6 vs 20.2 per 1000 patient-days; P = .21) did not differ significantly between the standard supervision and increased supervision groups.

Further, results were similar for both groups in a subgroup analysis restricted to patients admitted and discharged under the care of the same attending physician and in a subgroup analysis that compared attending physicians by years of experience.

When the researchers categorized severity of harm of adverse events using the National Coordinating Council Medication Error Reporting and Prevention severity categories E through H, most were only minor harm in both the standard and increased supervision groups (88.5% vs 88.6%; P = .50).

The two supervision groups did not differ significantly for secondary outcomes, including length of stay (median, 6.0 vs 6.0; P = .93), transfers to the intensive care unit (13.2% vs 15.9%; P = .22), deaths (2.6% vs 2.7%; P = .84), or discharge disposition (42.2% vs 42.4% discharged home; P = .85).

Residents Preferred Standard Supervision

The groups were similar in terms of durations of work rounds (202 vs 202 minutes in standard vs increased supervision minutes), duration of new-admission bedside presentations (105 vs 106 minutes), mean lengths of time junior residents spoke during work rounds (58 vs 57 minutes), and mean time patients and families spoke during work rounds (13 vs 13 minutes).

However, interns in the standard group spoke for a longer amount of time vs those in the increased supervision group (64 vs 55 minutes; P = .008).

The daily mean numbers of radiology studies ordered by residents and interns were the same for the two groups (0.39 vs 0.41] studies per patient-day; P = .75), as were the number of consultations (0.78 vs 0.87 per patient-day; P = .28) on their patients.

There was a nonsignificant trend for trainees to place more orders in the increased supervision teams compared with the standard supervision teams both between the hours of 7:00 AM and 12:00 PM (4.41 vs 5.35 orders per patient-day; P = .10) and between 12:01 PM and 5:00 PM (3.98 vs 5.13 orders per patient-day; P = .09).

When surveyed, residents and interns said they were less efficient, felt less autonomous, and were less able to make independent decisions when an attending physician participated on work rounds.

"Without the attending physician on work rounds, residents believed that they were the team's leader and their comfort in making independent patient care decisions improved," the researchers write.

Likewise, interns in the increased supervision group reported they received more feedback about the decisions they made, and supervision was "just right."

Although residents in both groups reported they provided the same quality of care and gave similar ratings for the learning environments, attending physicians reported "they knew the team's plan of care better, rated the quality of care higher, and felt more satisfied with the care provided when they participated on work rounds," the authors write. Attending physicians believed the educational experience was similar in both groups.

Findings Have Limited Generalizability, Authors and Editorialists Say

Both the authors and other experts caution that the findings may not be widely generalizable. "We share the authors' concerns about the limited generalizability of their findings given the selection bias inherent in studying high-performing residents at a single, tertiary, academic medical center. Studying faculty hand-selected for outstanding teaching skills and a deep understanding of adult learning theory may further bias the results," write J. Paul Happel, MD, from the Internal Medicine Residency Program, National Capital Consortium, and the Department of Medicine, Uniformed Services University of the Health Sciences, both in Bethesda, Maryland, and colleagues write in an invited commentary.

Moreover, Happel and colleagues question whether the researchers' approach for collecting medical error outcomes was "robust enough to adequately detect errors," and say the study may have been underpowered to identify harm.

"[S]upervision of trainees must not be viewed as a hindrance to resident education, but rather as a challenge to academic faculty to strike the right balance between mentorship and autonomy.... To help guide young physicians toward independent practice, we need as much time with our trainees as we can get, but really only as much as they need. Our faculty need the training as educators to provide that highly nuanced and balanced approach," the editorialists explain.

"Given the importance of graduated autonomy to adult learning and the value of peer learning, the decisions about level of supervision should consider the need for distance between teacher and student for learning to occur. The results of this study suggest that residency training programs reconsider the appropriate level of attending physician supervision in designing their morning rounds, balancing patient safety, excellent care, learner needs, and resident autonomy," the researchers conclude.

One coauthor reports partial support by the Children's Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings network and consults with and holds equity in the I-PASS Institute, which works to train institutions in best handoff practices and assist with their implementation. That coauthor also reports monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and has served as an expert witness in cases regarding patient safety and sleep deprivation. The remaining coauthors and editorialist have disclosed no relevant financial relationships.

JAMA Intern Med. Published online June 4, 2018. Article abstract, Commentary extract

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