Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.
Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.
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DOI：
10.1371/journal.pmed.0030487
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发表时间：
2006-12
期刊：
影响因子：
15.8
通讯作者：
Czeisler CA
中科院分区：
文献类型：
--
作者：
Barger LK;Ayas NT;Cade BE;Cronin JW;Rosner B;Speizer FE;Czeisler CA
最近在重症监护病房进行的一项随机对照试验显示，取消长时间轮班（≥24小时）可降低重大医疗差错和多导睡眠描记仪记录的注意力不集中的发生率。这引起了人们的关注，即实习生通常工作的长时间轮班可能会增加医疗失误的风险，并可能更普遍地增加不良事件的风险。我们目前的研究评估了在美国不同的实习生群体中，实习生工作的长时间轮班是否与重大医疗差错、不良事件和注意力不集中有关。我们在美国各地进行了一项基于网络的调查，其中有2737名居民在他们的研究生一年级（实习生）完成了17003份月度报告。通过病例交叉分析，每个实习生都作为他/她自己的对照，评估了当月长时间轮班的次数与重大医疗差错、可预防的不良事件和注意力不集中的报告之间的关系。与没有长时间轮班的月份相比，在工作1至4个长时间轮班和5个或更多长时间轮班的月份中，报告至少一个疲劳相关的重大医疗差错的比值比分别为3.5（95%置信区间[CI]， 3.3-3.7）和7.5 （95% CI, 7.2-7.8）。疲劳相关的可预防不良事件的比值比分别为8.7 （95% CI, 3.4-22）和7.0 (95% CI, 4.3-11)，也有所增加。每月轮班5次以上的实习生在讲课、查房和临床活动（包括手术）中注意力不集中的比例更高，与疲劳相关的可预防不良事件导致死亡的比例高出300%。在我们的调查中，在美国各地的实习生中，长时间的轮班与重大医疗差错、不良事件和注意力不集中的风险增加有关。这些结果对研究生医学教育具有重要的公共政策意义。在延长轮班的几个月里，与没有延长轮班的几个月相比，他们报告至少一次与疲劳有关的重大医疗失误的机会增加了3倍多。在美国，正在实习的医科学生（研究生临床培训的第一年）经常在诊所工作超过24小时。众所周知，长时间轮班工作的医生或学生会犯更多的医疗错误，而且注意力不太集中。每年成千上万的不良医疗事件，包括极端情况下的病人死亡，被认为是由医疗差错造成的，但目前尚不清楚医生或学生的长时间工作是否是造成这些差错的原因，而不是工作总时数的增加。这个研究小组想要找出实习生长时间轮班是否会对报告的医疗事故产生影响，从而影响病人的安全，特别是发生在病人身上的任何伤害是否本来是可以预防的。研究人员通过电子邮件联系了某一年级开始实习的所有美国医学院毕业生，并询问每个人是否愿意参加一项保密调查。同意参与的个人被引导到一个安全的网站，输入自己的基本信息，然后每月填写一份表格。在这张表格上，实习生们提供了他们的工作时间、睡眠时间、加班次数等信息，并完成了有关过去一个月医疗事故的问题。然后，研究人员对研究中的每个实习生每月的医疗事故数量和长时间轮班的数量进行比较。共有2737名实习生参与了这项调查。与没有长时间轮班的月份相比，在长时间轮班1到4次以及超过5次的月份里，医生报告至少一次与疲劳相关的重大医疗失误的可能性分别高出3倍和7倍。同样，与没有长时间轮班的月份相比，与疲劳相关的不良事件分别增加了约7倍和8倍。在每月工作超过5个延长轮班的实习生中，与患者死亡相关的疲劳相关的可预防不良事件增加了~ 300%；他们也更有可能在讲课、查房和临床活动（包括手术）期间睡着。美国的研究生医学教育指导方针仍然允许每月最多9次马拉松式轮班（每次30小时），尽管总工作时数是有上限的。这项研究表明，长时间轮班对病人的安全是不利的，因为他们更有可能造成原本不会发生的伤害。请通过本摘要的在线版本http://dx.doi.org/doi:10.1371/journal.pmed.0030487访问这些网站。美国食品和药物管理局在其网站上有关于用药错误的资源国家睡眠基金会旨在通过了解睡眠和睡眠障碍来改善公众健康和安全维基百科（任何人都可以编辑的互联网百科全书）有一个关于美国住院医师培训的页面
A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (≥24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality. In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education. During months in which medical interns worked extended shifts, the chances of their reporting at least one fatigue-related significant medical error increased more than 3-fold compared to months with no extended shifts. In the United States, medical students who are doing their internship (first year of postgraduate clinical training) regularly work in the clinic for longer than 24 h at a time. It is already known that doctors or students who work for long shifts make more medical errors and are less able to pay attention to what they are doing. Many thousands of adverse medical events per year including, in the extreme, deaths of patients, are thought to result from medical errors, but it is not clear whether doctors or students working long shifts—as opposed to, for example, an increase in total number of hours worked—are the cause of many or any of these errors. This research group wanted to find out whether long shifts worked by interns had an effect on reported medical errors, and hence patient safety, and specifically whether any harm that happened to patients might otherwise have been preventable. The researchers contacted all US medical school graduates beginning their internships from one particular year-group by email, and asked each person whether they wanted to take part in a confidential survey. Individuals who agreed to participate were directed to a secure website to enter basic information about themselves and then to complete a form each month. On that form the interns gave information about their working hours, hours of sleep, and number of extended-duration shifts worked, and completed questions about medical errors in the past month. Then, for each intern in the study, researchers compared month by month the number of medical errors and the number of extended-duration shifts that had been worked. A total of 2,737 interns took part in the survey. Compared to months in which no extended-duration shifts were worked, in those months in which between one and four, and more than five extended-duration shifts were worked, the doctors were, respectively, three and seven times more likely to report at least one fatigue-related significant medical error. Similarly, fatigue-related adverse events increased by around seven and eight times, respectively, compared with months in which no extended-duration shifts were worked. Fatigue-related preventable adverse events associated with the death of the patient increased by ∼300% in interns working more than five extended-duration shifts per month; they were also more likely to fall asleep during lectures, rounds, and clinical activities, including surgery. Guidelines for graduate medical education in the United States still allow up to nine marathon shifts (30 h at a stretch) per month, even though the total number of hours worked is capped. This study shows that the long shifts worked by interns are bad for patient safety, as they are more likely to cause harm that would not otherwise happen. Please access these Web sites via the online version of this summary at http://dx.doi.org/doi:10.1371/journal.pmed.0030487. The US Food and Drug Administration has resources on its website about medication errors The National Sleep Foundation aims to improve public health and safety by achieving understanding of sleep and sleep disorders Wikipedia (an internet encyclopedia anyone can edit) has a page about residency training in the United States
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影响因子：
5.6
作者：
CARSKADON, MA;DEMENT, WC
通讯作者：
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影响因子：
5.7
作者：
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通讯作者：
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