Effects of Attending Surgeon and Obstetrician Fatigue on Operating Room Safety

描述(由申请人提供)：在美国，每年有多达98,000名患者死于医疗差错。虽然护士和实习医生睡眠不足被发现显著增加了医疗差错和职业伤害的风险，但关于高级(主治医生)工作时间和病人安全之间的关系的信息很少。在外科和产科，主治医生的时间可以与实习医生持平，甚至超过。然而，如此长的工作时间是否会像住院医生那样严重地降低经验丰富的主治医生的表现，目前尚不清楚。与年轻的实习医生相比，有经验的主治医生可能不太容易出现注意力不集中和表现下降的情况，因为年轻的实习医生在长时间清醒时有更强的生理动力来睡觉。相反，睡眠质量往往会随着年龄的增长而恶化，这可能会导致睡眠债务的积累，并增加与疲劳相关的错误的风险。在之前的一项密集的观察性研究中，我们发现，与计划工作被限制在连续16小时内的医生相比，轮班工作24小时的实习医生产生的严重医疗错误多36%，严重诊断错误多5倍。我们建议对主治医生和产科医生进行一项深入的研究，以衡量手术中的护理过程和错误。在这样做的过程中，我们将利用我们自己对睡眠和医疗错误进行深入研究的经验，以及新出现的量化手术安全性和结果的工具。我们的具体目标将是：1.检验这样一种假设，即通过术中直接观察和医疗保健提供者报告进行前瞻性评估的技术性能问题的发生率，在过夜病例(即病例发生在凌晨12点至早上7点之间)后的第二天进行的手术病例中，将显著高于没有之前任何夜间工作的匹配病例。2.通过前瞻性的术中直接观察和提供者报告来评估注意力不集中、沟通不畅和团队合作问题的发生率，以检验这样一种假设：与没有任何前夜工作的匹配病例相比，在隔夜病例后第二天进行手术的病例中，注意力失误、沟通错误和团队合作问题的发生率将显著更高。3.通过直接观察、提供者报告和系统图表监测相结合的方法来评估手术中严重医疗差错(不良事件和险些发生)的发生率，以检验这样一种假设：与没有任何前夜工作的匹配病例相比，在隔夜病例后的第二天进行手术的病例中，严重医疗差错的发生率将显著更高。这项拟议的研究将建立在我们之前关于睡眠剥夺和安全的研究基础上，以帮助理解跨医学专业和培训水平延长工作时间的影响。公共卫生相关性：在美国，每年有44,000至98,000名患者死于医疗差错。我们之前发现，实习医生传统的长时间工作极大地增加了他们犯医疗错误的风险，但医学界仍然存在相当大的争论，即经验丰富的医生的表现是否会随着睡眠不足而恶化。我们计划在手术室进行一项密集的研究，使用已建立的直接观察技术和测量工具来确定睡眠不足是否会增加高级外科医生和产科医生出错的风险。

DESCRIPTION (provided by applicant): Up to 98,000 patients die each year in the United States due to medical error. While nurse and physician-in-training sleep deprivation has been found to significantly increase the risk of medical errors and occupational injuries, very little information has emerged on the relationship between senior (attending) physician work hours and patient safety. In surgery and obstetrics, the hours of attending physicians can match or exceed those of physicians-in-training. Whether such long work hours might degrade the performance of experienced attending physicians as severely as that of resident-physicians, however, is unknown. Experienced attending physicians may be less prone to attentional failures and performance decrements than younger physicians-in-training who have a stronger physiologic drive to sleep when awake for long hours. Conversely, sleep quality tends to deteriorate with age, which could lead to a buildup of sleep debt and an increased risk of fatigue-related error. In a prior intensive observational study, we found that physicians-in-training working recurrent 24-hour shifts made 36% more serious medical errors and five times as many serious diagnostic errors as those whose scheduled work is limited to 16 consecutive hours. We propose to conduct an intensive study of attending surgeons and obstetricians that will measure intra-operative processes of care and errors. In doing so, we will draw upon both our own experience conducting intensive studies of sleep and medical error, as well as emerging tools to quantify surgical safety and outcomes. Our specific aims will be: 1. To test the hypothesis that the incidence of technical performance problems - as prospectively assessed by direct intra-operative observation, as well as healthcare provider reports - will be significantly higher during surgical cases performed the day following an overnight case (i.e., a case occurring between 12am and 7am) compared with matched cases on days without any preceding night work. 2. To test the hypothesis that the incidence of attentional failures, miscommunications, and teamwork problems - as prospectively assessed by direct intra-operative observation, as well as provider reports - will be significantly higher during surgical cases performed the day following an overnight case compared with matched cases on days without any preceding night work. 3. To test the hypothesis that the incidence of intra-operative serious medical errors (adverse events and near misses) - as assessed by a combination of direct observation, provider reports, and systematic chart surveillance - will be significantly higher during surgical cases performed the day following an overnight case compared with matched cases on days without any preceding night work. The proposed study will build upon our prior studies of sleep deprivation and safety to help develop an understanding of the effects of extended work hours across medical specialties and levels of training. Public Health Relevance: Between 44,000 and 98,000 patients die each year in the United States due to medical error. We have previously found that the traditional long work hours of physicians-in-training greatly increase their risk of making medical errors, but there remains considerable debate in the medical community about whether experienced physicians' performance deteriorates with sleep deprivation. We plan to conduct an intensive study in the operating room using established direct observational techniques and measurement tools to determine if sleep deprivation increases senior surgeons' and obstetricians' risk of error.