Burnout Tied to Twofold Higher Risk for Medical Errors

Tara Haelle

July 09, 2018

Doctors who reported at least one major symptom of burnout were more than twice as likely to report a major medical error within the previous 3 months, according to a new study published online today in Mayo Clinic Proceedings

The study is based on a cross-sectional, observational survey, which precludes conclusions about causality or the association's directionality. But "it is conceptually likely that the two are reciprocal," write Daniel Tawfik, MD, MS, an instructor of pediatric critical care medicine at the Stanford University School of Medicine in Palo Alto, California, and colleagues.

They cite previous research showing that "self-perceived medical errors were found to predict subsequent burnout, while burnout was also found to predict subsequent perceived medical errors."

Tawfik told Medscape Medical News the most surprising finding from the new data is the strength of the relationship between burnout and errors after accounting for other factors, including work-safety grades.

"It shows that those work-safety grades don't tell the whole picture," he said. "They are an important reflection of practices in a unit, but they're only telling part of the story."

More Burnout, More Errors

The researchers used data from the American Medical Association Physician Masterfile to contact 94,032 physicians between August and October 2014, including physicians across all specialties. The invitation said the anonymous survey was about factors contributing to doctors' satisfaction and did not mention burnout. Overall, 35,922 physicians opened an invitation and 6695 (19%) completed the survey. Two thirds of the respondents (67%) were male; the median age was 56 years. The respondents worked a median of 50 hours a week.

The 60-question survey asked about burnout; well-being; fatigue; depression; suicidal thoughts; recent medical errors; and physicians' age, sex, relationship status, specialty, practice setting, and hours worked per week. Physicians were also asked to give their work area "an overall grade on patient safety" with one of the following: A (excellent), B (very good), C (acceptable), D (poor), or F (failing).

Standardized survey tools were used for burnout and well-being questions, and fatigue measured how the doctor felt in the past week on a 0-to-10 Likert scale (0 = worst); scores of 4 or lower were classified as excessive fatigue.

The medical errors question asked, "Are you concerned you have made any major medical errors in the last 3 months?" This wording, the authors explain, "is intended to identify recent events internalized as a major medical error; events identified in this way have been found to have a high correlation with actual medical errors."

Just over half (54%) of respondents reported at least one major symptom of burnout. One third (33%) reported excessive fatigue, and 6.5% reported suicidal ideation within the prior 12 months.

Only 3.9% rated their unit area with a poor or failing patient safety grade, but 10.5% reported making a major medical error within the previous 3 months.

The most common mistakes reported were an error in judgment (39%), wrong diagnoses (20%), and technical mistakes (13%). Deaths resulted from 4.5% of these mistakes, and 5.3% led to serious permanent morbidity. More than half of the errors (55%) did not appear to affect the patient's outcome. Specialties most likely to report an error were radiology, neurosurgery, and emergency medicine. Perceived errors were lowest among pediatric subspecialties, psychiatry, and anesthesiology.

Burnout, fatigue, and suicidal ideation were significantly associated with medical errors: 78% of the doctors who reported an error also reported burnout symptoms compared with 52% of doctors not reporting an error (P < .001). After accounting for demographic factors and hours worked per week, this difference translated to 2.2 greater odds of a mistake among those with burnout.

Similarly, nearly half (47%) of those who reported an error felt fatigue, compared with 31% of doctors without errors (P < .001). Odds of a perceived medical error increased 4% for each additional night a doctor was on call each week.

Suicidal ideation was twice as common among doctors who reported a major medical error than among those who didn't (13% vs 6%; P < .001). This finding fits with data on "second victim syndrome," in which physicians who make a serious medical error feel traumatized themselves by guilt, shame, and other negative emotions.

There are already data on the stress caused by errors, and burnout and errors likely contribute to one another, Albert W. Wu, MD, director of the Center for Health Services and Outcomes Research and a professor at the Armstrong Institute for Patient Safety and Quality at the Johns Hopkins School of Medicine in Baltimore, Maryland, told Medscape Medical News. But underlying factors may contribute to both, said Wu, who coined the term "second victim."

"It's just as likely that working in an unsafe environment, perhaps at an institution that does not place a sufficiently high priority on patient safety, may be the cause of both problems of burnout and errors," he said. "Perhaps structures work so that doctors are more prone to fatigue, and those things can cause errors, or those things can cause burnout that can cause errors."

After adjustment for age, sex, workload, and specialty, the risk for medical errors increased as a work unit's safety grade decreased. Compared with A-grade units, the odds ratio for perceived major medical error was 1.70 among those with a B grade, 1.9 with a C grade, 3.1 with a D grade, and 4.4 with an F grade. But these findings may illustrate an association similar to what Wu implied.

"It's not actually known if having a low work-unit safety grade means a lot of errors or if poor outcomes are happening because people are aware of the errors," Tawfik told Medscape.

The findings are not only not surprising but actually gratifying to Michael Hicks, MD, executive vice president for clinical affairs at the University of North Texas Health Science Center in Fort Worth, because they provide quantitative data to support long-time observations.

"The problem we have with American healthcare, probably global healthcare, is frequently the system is designed for optimal circumstances. The environment makes the assumption that everything is going to occur correctly and that people are playing at the top of their game," Hicks told Medscape Medical News.

"But frequently the workforce is not playing at the top of its game" because they are human. "If you put someone who is underperforming because of emotional or physical constraints in a system that's not designed to protect them from human frailty, I would be surprised if you got anything different than what they reported," he said.

Healthcare Needs Healthy Providers

An estimated 100,000 to 200,000 patients die of medical error each year, according to the National Academy of Medicine (formerly the Institute of Medicine), and serious nonfatal errors occur 10 to 20 times more often than fatal ones.

Previous research has found that about half of doctors feel burnout and only slightly less feel fatigue; doctors also die by suicide at rates three to five times greater than the general population, the authors note.

"We need to face the fact that high-quality healthcare depends on having healthy doctors and nurses," Wu said, pointing to the Joint Commission's report last year recommending healthcare organizations implement support structures for healthcare workers.

While the scientific community is appreciating the relationships between these phenomena more, it hasn't sufficiently filtered to clinical practice, Tawfik told Medscape Medical News.

"There has not seemed to be a culture shift yet where preventing burnout and promoting your own resilience is really viewed as an important part of your professionalism and improving your patient care," he said. "There still is very much a culture in medicine that says you need to work harder, ignore your own needs to do the best you can for your patients, without this recognition that it contributes to your own burnout, which can then adversely affect your patients." 

He said healthcare workers need to recognize and prioritize their own well-being, and institutions need to support them in that effort, including providing resources and training tools. But larger systemic changes will be necessary, too.

"One of the largest hypothesized predictors of burnout is just excess documentation, when physicians are spending more time on computers documenting what they're doing with the patient than they're actually spending with the patient," Tawfik said. He adds that such documentation is typically only for billing or regulatory requirements that can be changed. "It will take a lot of work to change them, and that can allow doctors to spend more time with patients and restore some of that joy of medicine."

Another essential shift is societal perceptions of healthcare workers themselves, Hicks said, referring to a "longstanding cultural bias [that] healthcare workers are different than other folks."

"One of the things that really needs to be addressed is this idea that physicians and nurses are super-human," he said. "We allow physicians and nurses to work hours that we would never allow bus drivers or airline pilots to work, and the systems we work in actually encourage us to work at what would be considered an unsafe level."

Physicians have shown themselves not to be adept at monitoring themselves, Hicks continued. Thus, it will require external forces, including from patients themselves, to make changes.

"I think patients and their families are going to have to ask tough questions of their caregivers around what kind of environment they're actually delivering care in," he said. "I think it's going to require asking questions like, When I show up for surgery, how long have you been up and how do you feel? And how do you work with the team?"

Change, then, will require shifts along the entire chain of care, from individuals up to systems, he said.

"When I think about the way these researchers approached this, the whole basis for patient safety is predicated on building better systems so that humans can be human," Hicks said. "You've got to build a system where we can do our job and be the best we can be, but catch us when we make a mistake or have a failure."

The research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Mayo Clinic Program on Physician Well-being. The authors have disclosed no relevant financial relationships.

Mayo Clin Proc. Published online July 9, 2018. Abstract

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