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Unintended Consequences – Depressing Isn’t It?

It seems that everything I read these days is depressing.  Again this week, just like my comments in a recent post on developing high reliability habits, I was reading an article in the literature that got me kind of down.  This one is written by Dr. Srijan Sen and coworkers at The University of Michigan who published a prospective cohort review study of resident work hours in last week’s issue of the Journal of the American Medical Association.  It looked at fatigue among their house officers and how reduced work hours had no impact, as a matter of fact a negative impact, on patient safety.  Over a twelve month study period, intern and resident concerns and reports of significant medical errors rose from 19% to 23% as duty hours decreased from 67 to 63 hours per week.

This isn’t an isolated finding either but has been substantiated in resident training board scores and in opinions of many surgical educators and I’ve wrestled with this in my capacity as a professor in a medical school.  At a recent surgical society meeting, Dr. L.D. Britt, chairman of the department of surgery at Eastern Virginia Medical School, compared the duty-hour restrictions to a Ponzi scheme for their failure to make a return on any investments.  He said that “since duty-hour limitations have been implemented, not one metric has improved, the failure rate on the certifying exam has gone from 14% to 29% in the past five years, and there has been no evidence that patient safety has improved.”  Making sure that our residents have less time on duty and more time to relax and sleep was supposed to lead to fewer medical errors, but our colleagues have pointed out exactly the opposite – so what’s up with that?

april 09-1How could fewer hours lead to more errors?  Pretty much everyone will know about the intended consequences of  an action they have designed to improve a system, but the unintended ones are much more difficult to anticipate and can really sneak up on us.  Adam Smith, an 18th century Scottish philosopher was probably the first one to write about it but the term “the law of unintended consequences” stuck in our vocabulary from a study published in 1936, “The Unanticipated Consequences of Social Action” by Robert K. Merton.  He looked at a wide variety of human activity where things do not go as planned, and paradoxes and strange outcomes were seen.  He called this a “perverse effect” and it happens when an action results in an outcome that is contrary to what was originally intended and the intended “solution” actually makes the problem worse.

The Juggler

Fritz Beinke 1873: The juggler (Der Jongleur)

So what could the “perverse effects” of limiting work hours be?  It is interesting and informative to look at the kind of errors that were reported by the study group.  One set of errors was that, while they weren’t working as many hours, they were still expected to take care of the same amount “scut work” so they had less time to juggle all these balls in the air and get their assigned work done.  This led to “work compression”, that increased the risk of errors and mistakes since the residents didn’t have as much time to make and re-check patient care decisions and follow up on lab results and test details.

Another source of errors occurred as interns leaving handed off their patients to the incoming group who are not as familiar with the patients’ histories and even less emotionally invested in their care.  The study noted that with fewer work hours, the number of handoffs increased from an average of three during a single shift to as many as nine.  Errors occurred due to imprecise communications, failure to exchange the “big picture” of the patient’s current condition and also when the big picture gestalt walked out of the door with the residents being relieved for the day.  Clearly this risk is incrementally increased when the hand offs occur several times over each day.  Handoffs are notoriously fraught with miscommunication and are known from the high reliability literature to be a major time when mistakes are made.

Is there an answer for these unintended outcomes in the high reliability skill set we have talked about on this site and adopted into our practice?  Sure, it has to do with team work, team skills, and the high reliability mindset communication skills, and tools for hand offs I’ve talked about in previous blog posts.  This study shows that there are lapses and gaps in patient care as residents come and go for their time on duty.  But with our high reliability mindset skills there are ways we can be sure that there are never times when there is not primary ownership of a patient and their changing medical condition especially during hand offs when they are exposed to risks of medical errors.  As medical educators and advocates of the high reliability mindset we must use, teach and advocate for precision in communications, complete and accurate hand offs and, as in the last post, the highest constant levels of professionalism.

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