Patient Safety and Quality

Rates of adverse medical events and motor vehicle incidents are unchanged among U.S. resident pediatric physicians despite duty hour limit standards

A new study comparing medical errors, motor vehicle crashes, and other problems associated with sleep deprivation among pediatric residents found little change in these problems after implementation of new limits on duty hours issued in 2003 by the Accreditation Council for Graduate Medical Education (ACGME). Christopher P. Landrigan, M.D., M.P.H., of Harvard Medical School, and colleagues, conducted the study in three major teaching hospitals and conclude that stricter limitations on duty hours, similar to those in place in Europe (where shifts are limited to 13 consecutive hours and a total of 48 to 56 hours per week) are needed to improve both patient and resident safety.

The ACGME duty hour standards limit extended duty shifts for resident physicians to no more than 30 hours and no more than 80 to 88 hours per week, averaged over 4 weeks. Before implementation of the standards, residents frequently worked more than 30 hours in a row and more than 80 hours per week on rotations at the participating hospitals. However, the researchers found that the mean duration of extended work shifts decreased by only 3 percent, from 29.3 hours before implementation of the standards to 28.5 hours afterwards. Prior to implementing the ACGME standards, 81 percent of residents reported working shifts exceeding 30 consecutive hours. After implementation, over half (56 percent) continued to work shifts of more than 30 hours.

The researchers found no significant change in total medication error rates, from 1.29 errors per 100 orders before implementing the new work limits to 1.50 errors per 100 orders afterwards. The total rate of adverse events did not change (from 0.16 adverse events per 100 orders before the new rules to 0.17 afterwards). Rates of near-miss motor vehicle collisions, actual motor vehicle collisions, direct exposure to blood or another bodily fluid (often due to fatigue-related errors), and self-reported medical errors did not differ significantly before and after the implementation of the guidelines. Finally, rates of depression on a validated survey did not differ before and after the change in duty hour rules, but rates of burnout dropped significantly, from 75 percent to 57 percent.

The study was funded in part by the Agency for Healthcare Research and Quality (HS13333). More details are in "Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours and safety," by Dr. Landrigan, Amy M. Fahrenkopf, M.D., M.P.H., Daniel Lewin, Ph.D., and others in the August 2008 Pediatrics 122(2), pp. 250-258.

Editor's Note: The Institute of Medicine recently released Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, which confirms that acute and chronically fatigued residents are more likely to make mistakes and recommends changes to the existing work-hour limits. The report is the result of a 15-month study funded by AHRQ. For additional details, go to New report recommends strategies to reduce medical resident fatigue-related errors and improve training.

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