The Human Factor: The Impact of
Work Hours, Sleep Deprivation, and
Burnout on Patient Safety
Tuesday, March 20, 2007
8:00 – 9:00 p.m. EDT
Moderator:
Christopher Landrigan, MD, MPH, FAAP
Pediatric Hospitalist, Research and Fellowship Director
Children’s Hospital Boston, Inpatient Pediatrics Service
Boston, Massachusetts
This activity was funded through
an educational grant from the
Physicians’ Foundation for Health
Systems Excellence.
Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME Activities Grid
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DISCLOSURES
Activity Title:
Safer Health Care for Kids - Webinar
The Human Factor: The Impact of Work Hours, Sleep
Deprivation, and Burnout on Patient Safety
Activity Date:
March 20, 2007
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP
CME activities are required to disclose to the AAP and subsequently to
learners that the individual either has no relevant financial relationships or
any financial relationships with the manufacturer(s) of any commercial
product(s) and/or provider of commercial services discussed in CME
activities.
Name
Name of
Commercial
Interest(s)*
(*Entity
producing
health care
goods
or services)
Nature of
Relevant
Financial
Relationship(s)
(If yes, please list:
Research Grant,
Speaker’s Bureau,
Stock/Bonds
excluding mutual
funds, Consultant,
Other - identify)
CME Content Will
Include
Discussion/
Reference to
Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses of Products
AAP CME faculty are required to disclose to the AAP
and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices
that are not approved
Amy Fahrenkopf,
MD, MPH
No
No
No
No
Mark Joffe, MD,
FAAP
No
No
Yes
No
DISCLOSURES
SAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Karen Frush, MD, FAAP
(PAC Member)
No
No
No
No
Uma Kotagal, MD, MBBS,
MSc, FAAP (PAC Member)
No
No
No
No
Christopher Landrigan, MD,
MPH, FAAP (PAC Member)
No
No
No
No
Marlene R. Miller, MD, MSc,
FAAP (PAC Chair)
No
No
No
No
Paul Sharek, MD, MPH.
FAAP (PAC Member)
No
No
No
No
Erin Stucky, MD, FAAP (PAC
Member)
No
No
Not sure
No
Nancy Nelson (AAP Staff)
No
No
No
No
Melissa Singleton, MEd
(Project Manager – AAP
Consultant)
No
No
No
No
Junelle Speller (AAP Staff)
No
No
No
No
Linda Walsh, MAB (AAP
Staff)
No
No
No
No
DISCLOSURES
AAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME)
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Ellen Buerk, MD, FAAP
No
No
No
No
Meg Fisher, MD, FAAP
No
No
No
No
Robert A. Wiebe, MD, FAAP
No
No
Not sure
No
Jack Dolcourt, MD, FAAP
No
No
No
No
Thomas W. Pendergrass, MD,
FAAP
No
No
No
No
Beverly P. Wood, MD, FAAP
No
No
No
No
CME CREDIT
The American Academy of Pediatrics (AAP) is
accredited by the Accreditation Council for
Continuing Medical Education to provide continuing
medical education for physicians.
The AAP designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 Credit™.
Physicians should only claim credit commensurate
with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credit.
This credit can be applied toward the AAP CME/CPD
Award available to Fellows and Candidate Fellows of
the American Academy of Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of
Pediatric Nurse Practitioners (NAPNAP) for 1.2
NAPNAP contact hours of which 0.0 contain
pharmacology (Rx) content. The AAP is designated
as Agency #17. Upon completion of the program,
each participant desiring NAPNAP contact hours
should send a completed certificate of attendance,
along with the required recording fee ($10 for
NAPNAP members, $15 for nonmembers), to the
NAPNAP National Office at 20 Brace Road, Suite 200,
Cherry Hill, NJ 08034-2633.
The American Academy of Physician Assistants accepts
AMA PRA Category 1 Credit(s)TM from organizations
accredited by the ACCME .
The Human Factor: The Impact of
Work Hours, Sleep Deprivation,
and Burnout on Patient Safety
American Academy of Pediatrics Webinar
March 20, 2007
Christopher P. Landrigan, MD, MPH
Director, Sleep and Patient Safety Program, Brigham and Women’s Hospital
Research Director, Children’s Hospital Boston Inpatient Pediatrics Service
Assistant Professor of Pediatrics and Medicine, Harvard Medical School
To Err is Human
(Institute of Medicine, 1999)
• 44,000 to 98,000 deaths per year due to adverse
events
• Focus on systemic issues
• Report notably silent on issue of provider working
conditions and mental health
– lack of empiric data at that time
• Considerable accumulation of information in past
3-4 years
Resident Performance and Fatigue
Philibert I. Sleep 2005; 28: 1392-1402.
• Meta-analysis 60 studies
(959 MDs, 1028 non-MDs)
– For MDs, 24 hours with
no sleep leads to major
performance drops to:
-4
-3 -2
-1
0
1
2
3
4
Standard Deviations
•Effect of Sleep Deprivation on
Physicians’ Mean Clinical
Performance: Results of 14 Studies
• 15th percentile of rested
MD performance level
• 7th percentile on clinical
tasks
Harvard Work Hours, Health, and
Safety Study
• National Study of Work Hours and Injuries in 2,737 Interns
Motor Vehicle Crashes
1.2
OR: 2.3 (95% CI, 1.6-3.3)
Percutaneous Injuries
1.4
OR: 1.6 (95%CI, 1.5-1.8)
Extended
shifts
1.2
1
Nonextended
shifts
1
0.8
0.8
0.6
0.6
0.4
0.4
0.2
0.2
0
0
Crashes per 1000 commutes home
Barger LK et al. NEJM 2005;
352:125-134
Injuries per 1000 opportunities
Ayas, et al. JAMA 2006;
296:1055-1062
Intern Sleep and Patient Safety Study
•Randomized Trial comparing interns’ alertness and
performance on traditional “q3” schedule with 24-30 hour
shifts (ACGME-compliant ) vs. 16 hr max schedule
No. of attentional failures from
11pm – 7am per Hour on Duty
•Twice as many EEG-documented attentional failures at night
on traditional schedule
0.8
p=0.02
0.7
0.6
Traditional
"q3" 24-30
hour shifts
0.5
0.4
Intervention
Schedule <16 hour
scheduled
shifts
0.3
0.2
0.1
0
Attentional Failures at Night
Lockley, S. W. et al. N Engl J Med 2004;351:1829-1837
Intern Sleep and Pt Safety Study, Part 2
•Interns made 36% more serious errors on traditional schedule,
including 5 times as many serious diagnostic errors
Errors per 1000 pt days
160
p<0.001
140
120
Traditional "q3" 24-30
hour shifts
p=0.03
100
Intervention Schedule
- <16 hour scheduled
shifts
80
60
40
p<0.001
20
0
Serious
Medical Errors
- Total
Serious
Medication
Error
Serious
Diagnostic
Error
Landrigan,
N Engl
J Med
2004;351:1838-1848
Landrigan, C.C.P.
P. etet
al.al.
N Engl
J Med
2004;351:1838-1848
ACGME Duty Hour
Standards
• <80 hours per week, averaged over
four weeks
• <30 hours in a row, including time
for hand-offs of care and education
• 1 day off in 7, averaged over four
weeks
• Implemented in July 2003
• Goal to reduce extreme work hours, and
consequently improve patient safety
ACGME Duty Hours Compliance
Study
• 83.6% of interns in violation of standards during
at least one month of the year
• 61.5% of all inpatient intern-months in violation
Work and Sleep, Pre- vs. Post-Implementation
‡
p<0.001
Landrigan C.P., et al. JAMA 2006;296:1063-1070
‡
p<0.001
Patient Safety, Resident Sleep,
Depression, and Burnout
• Mark Joffe: sleep deprivation and
human performance
• Amy Fahrenkopf: burnout, depression,
and resident performance
Mark Joffe, MD, FAAP
Director, Community Pediatric Medicine
The Children’s Hospital of Philadelphia
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
The Human Factor:
The Impact of Work Hours, Sleep
Deprivation, and Burnout on
Patient Safety
Mark Joffe, M.D.
The Children’s Hospital of Philadelphia
“Physician, heal thyself!”
Consequences of Sleep
Deprivation
• Decreased longevity in animal models
• Chronic hypertension
• Increased cardiovascular mortality
( > 1 PPD cigarettes)
• Infertility
• Injuries
Social Cost of Sleep Deprivation
• Depression
• Divorce
• Alcohol / Drug Addiction
Chernobyl 1:23 AM
Bhopal 12:40 AM
Three Mile Island 4:00 AM
8A
6A
4A
12
A
2A
P
10
8P
6P
4P
2P
10
A
12
P
8A
Error Rate vs Time of Day
Car Crashes vs Time of Day
1200
1000
800
600
400
200
0
8 10 12 14 16 18 20 22 0 2 4 6
Hour of Day
Federal Regulations
for Truckers
10 hour maximum without break
15 hour max without 8 hour break
60 driving hours/7day period
Fatigue-Related Impairments
•
•
•
•
•
•
Passive vigilance
Reaction time
Hand-eye coordination
Clerical accuracy
Memory
Reasoning
Provider Fatigue vs Performance
meta-analysis, resident physicians
• Sleep debt < 30 hrs
– Overall performance reduced 1 std deviation
– Clinical Performance reduced 1.5 std deviation
Philibert
Provider Fatigue vs Performance
Outcomes: attention and simulated driving
• Heavy call vs light call (residents)
– Reaction time
– Commission errors
– Lane variability
– Speed variability
7% slower
40% greater
27% greater
71% greater
– Post-call performance equal to 0.05 g%
blood alcohol
Arnedt
Provider Fatigue vs Alcohol
effects on performance
• 18-24 hours of continuous wakefulness
causes performance decline equal to
blood alcohol level of 0.1%
(William, Dawson)
Fatigue-related impairment expressed as
“blood-alcohol equivalent”
Provider Fatigue and Medical Errors
• Medication errors 2.5 times more likely
between 4-8 AM
(Kozer)
• Fatigued surgeons make 20% more
errors in simulated laporoscopic surgery
(Taffinder)
Physiology of Sleep
Circadian cycling promotes the
acquisition of regular and
adequate sleep
 Overcoming this intrinsic biological
predisposition is very, very difficult
Circadian Timekeeping
• A property of all higher life forms
• Humans evolved to work during the
daylight hours
• “After-hours” work is a recent societal
need that is out of harmony with our
evolutionary inheritance
Circadian Rhythms
• Organisms have their own endogenous
biological clock
• Circadian rhythms are affected by
endogenous and exogenous factors
• Exogenous time setters – “Zeitgebers”
light more potent than cultural/social cues
Suprachiasmatic Nucleus
• Locus of biologic rhythmicity
• Neurons have circadian rhythmicity that
is intracellular in origin
• Genes coding for the clock function
have been identified
Body Temperature Cycle
O
F
99
99
sleep
Sleep
98
97 97
88
1212
1616
Hour
2020
0MN 4 4
8 8
Measures of alertness track closely
with body temperature, with nadirs
is the very early morning
Mean Leg Strength
after westward flight across 5 time zones
1600
Newtons
1550
1500
Day 1
Day 3
Day 5
Day 7
1450
1400
1350
1300
1250
700
1200
1700
Hour of Day
2100
Sleep Architecture
• Stage 1– if awakened people say they
weren’t asleep. Automatic behavior may
be Stage 1 sleep
• Stage 2 – half of sleep time in stage 2
Comes between periods of deep
sleep and REM
Stages 3 - 4
(Slow wave or delta sleep - SWS)
Most vital, for recuperation, immune
function
First to be made up after sleep deprivation
SWS increases after intellectually
challenging tasks
Most SWS occurs during the first half of
the sleep period
REM
(“brain on, body off”)
•
•
•
•
Rapid eye movements
Wakeful EEG pattern
Increased cerebral blood flow
Absent spinal reflexes
Sleep Architecture
W
1
REM
2
3+4
(SWS)
1
2
3
75% SWS
4
5
6
7
75% REM
8
Slow Wave Sleep deprivation is
associated with reduction in
cognitive performance
REM Deprivation
• Moodiness
• Hypersensitivity
• Inability to consolidate complex learning
REM appears to be important for
psychological well-being
Sleep Debt
• Sleep latency can be measured
• Very poor correlation between self-reported
sleepiness and objective measures of
fatigue
Variability in Sleep Requirements
• > 7 1/2 hours is optimal for most adults
• Tolerance of sleep deprivation varies
• “Night owls” vs “early birds”
Light and Melatonin
• Bright light very early in the morning can
cause a phase advance
• Melatonin secreted by pineal gland
signals brain that it is time to sleep
• Light suppresses melatonin secretion
Bright lighting can reduce
fatigue for workers forced
to work at night
Sedative-Hypnotics
• Alcohol causes sleep fragmentation
and decreased REM
• Most sedative-hypnotics disrupt the
architecture of sleep
Age Effects
• REM and melatonin secretion decreases
• Quality not maintained over 12 hour shifts
• Do not tolerate irregular shifts, disrupted sleep
as well as younger workers
• Age correlates with increased “morningness”
At what age should overnight coverage end?
Circadian Adjustment
• Circadian shift of 1-2 hours per day is
maximum
• Days off on regular schedule shifts
cycle back towards normal
It takes at least a week and usually longer to
adjust to a new shift
Short-term
Countermeasures
Strategic Napping
• Schedule your sleep as you schedule
your work
• Avoid caffeine and alcohol before nap
time
• Darken the room
• Make sure room is quiet or have white
noise (micro-awakenings decreases
time in SWS and REM)
Napping
• 23,681 Greek adults
• Controlled for diet, other confounders
• Mean 6.3 yr follow-up
• Regular “siesta” was associated with 37%
reduction in coronary mortality
(Naska)
Interventions - caffeine
‘World’s most popular drug’
• Mild CNS stimulant
• 3.5 - 6 hr half-life
• 250 mg improves psychomotor
function if sleep deprived, 500 mg side
effects w/o improvement
• Tachyphylaxis
• Withdrawal headaches
• Affects sleep latency and sleep quality
Do you know what dose you’re taking?
•
•
•
•
•
•
•
•
•
•
•
No-Doz max strength
Brewed Coffee (average)
Excedrin (2)
Instant Coffee
Mountain Dew
Orange Pekoe Tea
Coke Classic
Hershey’s Dark Chocolate
Green Tea
Hershey’s Milk Chocolate
Decaffeinated Coffee
200 mg
135 mg
130 mg
100 mg
55 mg
50 mg
35 mg
30 mg
30 mg
10 mg
5 mg
Modafinil
“Provigil”
• Narcolepsy
• Obstructive Sleep Apnea
• Military “short-term fatigue
countermeasure”
• Shift Work Sleep Disorder
The only way to completely
reverse the physiologic need
for sleep is to sleep
Summary
• The evidence that fatigue impairs
human performance is incontrovertible
• Physicians are human
• Fatigue is a root cause of many medical
errors
Summary
Optimizing performance requires that
sleep management be high-priority!
– Schedule clinical work with sleep in mind
– Just say no to meetings and other commitments
that disrupt optimal sleep management (and
expect it from colleagues)
– Family life must accommodate to sleep needs for
physicians with after-hours responsibilities
References
1. Naska A, Oikonomou E, Trichopoulou A. Siesta in healthy adults and coronary
mortality in the general population. Arch Intern Med 167:296, 2007.
2. William AM, Feyer A. Moderate sleep deprivation produces impairments in
cognitive and motor performance equivalent to legally prescribed levels of
alcohol intoxication. Occ Environ Med 57(10):649-655, 2000.
3. Philibert I. Sleep loss and performance in residents and nonphysicians: a
meta-analytic examination. Sleep 28(11):1392, 2005.
4. Arnedt JT, Owens J, et al. Neurobehavioral performance of residents after
heavy night call vs after alcohol ingestion. JAMA 294(9):1025, 2005.
5. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature
388(6639):235, 1997.
6. Taffinder NJ, McManus IC, Gul Y, et al. Effect of sleep deprivation on
surgeons’ dexterity on laparoscopy simulator. Lancet 1191:352, 1998.
7. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in
hospitalized patients. NEJM 324(6):377-384, 1991.
8. Institute of Medicine, To Err is Human, National Academy Press 2000,
Washington, D.C., p 49.
9. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug
events in pediatric inpatients. JAMA 285:2114-2120, 2001.
10. Kozer E, Scolnik D, Macpherson A, et al. Variables associated with medication
errors in pediatric emergency medicine. Pediatrics 110(4):737-742, 2002.
References
11. Dement WC. The Promise of Sleep, Delacorte Press, NY 1999, p262-263.
12. Akerstedt T, Knutsson a, AlfredssonL, et al. Shift work and cardiovascular
disease. Scand J Work Environ Health 10:490, 1984.
13. Earnest DJ, Liang F, Ratcliff M, et al. Immortal time: Circadian clock
properties of rat suprachiasmatic cell lines. Science 283(5404):693, 1999.
14. Van Dongen HP. Baynard MD. Maislin G. Dinges DF. Systematic
interindividual differences in neurobehavioral impairment from sleep loss:
evidence of trait-like differential vulnerability. Sleep. 27(3):423-33, 2004.
15. Van Dongen HP. Vitellaro KM. Dinges DF. Individual differences in adult
human sleep and wakefulness: Leitmotif for a research agenda. Sleep
28(4):479-96, 2005.
16. Weitman ED, Moline ML, et al. Chronobiology of aging: Temperature, sleepwake rhythms and entrainment. Neurobiol Aging 3:299-309, 1982.
17. Reid K, Dawson D. Comparing performance on a simulated 12 hour shift
rotation in young and older subjects. Occ Environ Med 58(1):58-62, 2001.
18. Landrigan CP, Rothschild JM, et al. Effect of reducing interns’ work hours on
serious medical errors in intensive care units. NEJM 351(18):1838, 2004.
19. van Duinen H, Lorist MM, Zijdewind I. The effect of caffeine on cognitive task
performance and motor fatigue. Psychopharmacology. 180(3):539-47, 2005.
20. Czeisler CA, Walsh JK, Roth T, et al. Modafinil for excessive sleepiness
associated with shift-work sleep disorder. NEJM 353(5):476, 2005.
Amy Fahrenkopf, MD, MPH
Pediatric Hospitalist
Children’s Hospital Boston
Boston, Massachusetts
Effects of Housestaff Burnout and Depression
on Patient Safety
American Academy of Pediatrics Webinar
March 20, 2007
Amy M. Fahrenkopf, M.D., M.P.H.
Department of Medicine
Children’s Hospital Boston
Introduction
• Depression and burnout are highly
prevalent among medical residents
• Studies have documented burnout rates
of 41-76%, while depression rates have
ranged from 7-56%
• Despite their frequency, little research
has sought to quantify the effects of
depression and burnout on patient care.
Burnout: Definition
• Burnout is a syndrome of emotional depletion
and detachment that develops in response to
chronic occupational stress
• Burnout more likely to develop when job
stress is high and personal autonomy is low
• Differs from depression in that it primarily
affects functioning within the work context,
not other areas of an individual’s life
Burnout: Screening
• Maslach Burnout Inventory
– Gold standard for evaluating burnout
– 22 question validated screening tool
– Version available that is specific to health
care industry
– Identifies three domains of burnout:
• Emotional exhaustion
• Depersonalization
• Low personal achievement
Burnout in Residency:
What do we know?
• Growing area of research, though studies
tend to be small and single-centered
• Burnout is a significant problem in all
specialties
–
–
–
–
–
Medicine: 41-76%
OB/Gyn: 50%
Pediatrics: 76%
Anesthesia: 47%
Surgery: 50-56%
Burnout in Residency:
What do we know?
• Burnout levels rise quickly within the first few
months of residency
• Burnout affects residents of all PGY levels
equally, although depersonalization scores
rise with each additional year of residency
• Men may be affected more than women
• ACGME work hour changes appear to have
decreased burnout rates moderately, but
study results have been contradictory
Depression:
Definition and Screening
• Depressed mood and loss of interests for at
least two consecutive weeks that interferes
with daily life and normal functioning
• In any given 1-year period, 9.5% of the
general population will suffer from a
depressive episode
• Clinical diagnosis with many excellent,
validated screening tools available
Depression in Residency:
What do we know?
• Considerably less research done on resident
depression than on burnout
• Studies report prevalence rates from 7-56%
• Studies to date focus solely on intern year
• Multiple studies have shown residents start
intern year with low rates of depression (24%) and jump to 30-56% within 3 to 6 months
Depression in Residency:
What do we know?
• Most depressed residents are also
burned out (80-95%)
• Most residents who screen positive for
depression in these studies have no
prior history of depression
• Female residents more likely to be
depressed
Depression and Burnout:
Is there a link to medical errors?
• All published studies to date have
focused on burnout and the link to selfreported medical errors or quality of
care
• No published study has attempted to
link depression to medical errors
• We will look at three studies that
highlight the important issues
Burnout and Self-Reported Patient Care in
an Internal Medicine Residency Program
Shanafelt TD, Bradley KA, Wipf JE, Back AL; Ann Intern Med. 2002;
136:358-367
• Survey of 115 internal medicine
residents at University of Washington
• Burnout measured by MBI
• Self-reported patient care determined
using tool developed for this study
• Depression measured using twoquestion PRIME-MD screen
Burnout and Self-Reported Patient Care in
an Internal Medicine Residency Program
Shanafelt TD, Bradley KA, Wipf JE, Back AL; Ann Intern Med. 2002;
136:358-367
• 76% burnout rate, of whom 50% also
screened positive for depression
• Burned out residents significantly more likely
than non-burned out residents to report one
or more suboptimal patient care monthly
(53% vs 21%; p=0.004)
• In multivariate analyses burnout (but not sex
or depression) associated with self-report of
suboptimal patient care monthly (odds ratio
8.3 [95% CI, 2.6-26.5])
Association of Perceived Medical Errors
with Resident Distress and Empathy
West CP, Huschka MM, Novotny PJ, et. al. JAMA. 2006; 296:1071-1078
• Prospective longitudinal cohort study of 184
internal medicine residents at Mayo Clinic
• Residents completed surveys of their quality
of life and self-reported medical errors every
three months for one year
• Quality of life survey included MBI, 2-question
depression screen, and a validated quality of
life scale
Association of Perceived Medical Errors
with Resident Distress and Empathy
West CP, Huschka MM, Novotny PJ, et. al. JAMA. 2006; 296:1071-1078
• 34% of residents reported making at
least one major medical error
• Self-perceived errors were associated
with increased burnout in all domains
(DP +3.23, p<0.001; EE+6.85, p<0.001;
PA –2.99, p=0.001)
Association of Perceived Medical Errors
with Resident Distress and Empathy
West CP, Huschka MM, Novotny PJ, et. al. JAMA. 2006; 296:1071-1078
• Self-perceived errors associated with
odds ratio of 3.29 (95%CI, 1.90-5.64) of
screening positive for depression at
next survey point
• Increased burnout scores, in turn,
associated with increased odds of selfreported errors in following 3 months
Rates of Medication Errors Among
Depressed and Burned Out House Officers
Fahrenkopf AM, Sectish TC, Barger LK, et.al (Presented at )
• Prospective cohort study of 123 pediatrics
residents at 3 large Children’s Hospitals:
– Children’s Hospital Boston
– Lucile Packard Children’s Hospital
– Children’s National Medical Center
• Involved 3 components:
– Baseline resident questionnaire with MBI and 10
question HANDS depression screen
– 6 week resident sleep and work hour logs
– Medication error collection at two sites
Housestaff Burnout and Depression:
The Link to Patient Safety
Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation,
Agency for Healthcare Research and Quality Patient Safety Conference,
Washington D.C., 2006
• 19.5% of residents depressed and 74%
burned out
• 96% of depressed residents also burned out
• 74% of those depressed had no prior history
of depression
• No correlation between depression or burnout
with PGY year, gender, marital status, or selfreported sleep or work hours
Housestaff Burnout and Depression:
The Link to Patient Safety
Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation,
Agency for Healthcare Research and Quality Patient Safety Conference,
Washington D.C., 2006
• 10,277 orders reviewed with 125 errors
identified
• 45 errors made by study subjects
– 0 preventable adverse drug events, 28 potential
adverse events, and 17 errors with little
potential for harm.
– 1 non-preventable ADE
Housestaff Burnout and Depression:
The Link to Patient Safety
Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation,
Agency for Healthcare Research and Quality Patient Safety Conference,
Washington D.C., 2006
1
Depression, Burnout, and Medication Errors per Resident-Month
resident-month
Errors
Errors
perper
Resident-Month
4
‡‡‡p<0.001
3
2
1
0
2
3
‡p<0.05 ‡‡ p<0.01
‡‡‡
depressed
burned out
not
depressed
‡p<0.05
‡‡ p<0.01
not
burned out
‡‡‡p<0.001
Housestaff Burnout and Depression:
The Link to Patient Safety
Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation,
Agency for Healthcare Research and Quality Patient Safety Conference,
Washington D.C., 2006
Depression, Burnout, and Self-reported Medical Errors
‡
Has made
"significant"
medical error
due to sleep
deprivation
‡
Not burned out
Burned out
Not depressed
Has made
"significant"
medical error
due to any
cause
Depressed
0
10
20 30
‡p<0.05
40 50 60
‡‡ p<0.01
70 80
‡‡‡p<0.001
90 100
Areas for Further Research
• Investigate the causal relationship between
depression and errors
• Better define how depression and burnout
affect residents and patient care in other
specialties AND among fellows and practicing
physicians
• Rigorously conducted intervention trials are
needed to evaluate how to improve the
mental health of trainees while decreasing
medical errors and preserving educational
quality.
Conclusion
• Depression and burnout are significant
problems among pediatric residents in all
years of training
• Both depressed and burned out residents
self-report high rates of errors and poor
health
• Preliminary studies suggest that depressed
residents have a nearly eight-fold increase in
errors compared to their non-depressed
colleagues
Conclusion
• ACGME work hour regulations may
have decreased burnout, but no change
in depression
• Further studies are needed to better
establish the relationship between
depression, burnout, and medical errors
Acknowledgements
Pediatric Work Hours Study Group
Harvard Work Hours, Health and Safety Group
Christopher Landrigan, MD, MPH