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Thursday, February 4, 2010

What we have known all along: ACGME's review of guidelines for residents' work hours

I still remember the helpless fear I felt on a bus in 1978 as we twisted our way along the narrow hilly road leading to Jerusalem, steered by a sleepy bus driver. Each time he nodded off, his head then snapped right up again. Thank God, we arrived safely.

But God didn't prevent an accident from exhaustion when my son was born, 12 years later. Going into premature labor eight weeks early, my wife was admitted to a Harvard teaching hospital, where doctors delayed her childbirth for a week. Then when hearing one evening that she was experiencing abdominal pain, the sleep-deprived residents confidently attributed them to gas pains! Finally the next morning, a pelvic exam revealed her cervix was nearly fully dilated, ready for delivery. Exhaustion had ruined their judgment, so my wife had to suffer the pain of childbirth for 12 hours without any pain medication.

Now the Accreditation Council on Graduate Medical Education (ACGME) may start facing what we have known all along: exhaustion creates errors. Even for very intelligent and dedicated doctors. At ACGME's Board meeting on Feb. 7 they'll consider whether to restrict the hours that hospital residents can work.

Supporters of the status quo say that shorter work hours require more dangerous hand-offs from one doctor to another. This is seductive but misleading. Yes, sometimes an alert and well-rested resident hands off the responsibility for a patient's care to another alert and well-rested resident, and communicates clearly and comprehensively. But much more often, an exhausted resident hands off to a chronically sleep-deprived resident. We know that exhaustion fogs memory, and clouds judgment and complex thinking, like the ability to prioritize and summarize. So it's hard to imagine that hand-offs as they are now performed consistently provide a clear and thorough briefing for a patient's care.

The best solution is both to reduce the use of exhausted residents, and thoughtfully improve the hand-off process. Error-proof it by minimizing the reliance on memory. For example, how about a "Hand-off" command in the electronic medical record system that could automatically summarize the patient's diagnosis and recent key lab results and vital signs for a doctor coming on shift? Or the audio recording of the hand-off communication as it occurs, for prompt automatic transcription into the electronic medical record?

A bereaved mother and national patient safety leader – Helen Haskell – organized a press conference today on these topics. She is leading an effort to reduce residents' work hours – which could have saved the life of her 15-year-old son, Lewis Blackman. See the new website on shortening residents' work hours, and share your story there.

Would you want my Israeli bus driver as your child's doctor in the hospital?

Read a fatal fatigue error story.

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