Researchers at the Institute of Medicine (IOM, Washington, DC, USA) performed a 15-month study examining the associations between residents' work schedules, their performance, and quality of care provided, under the auspices of the U.S. Agency for Healthcare Research and Quality (AHRQ, Rockville, MD, USA). Based on their study results, the IOM researchers recommend that (1) residents who complete a 30-hour shift may treat patients for only up to 16 hours, followed by a 5-hour protected sleep period between 22:00 and 08:00, during which time patient care would be managed by other residents or additional staff members. (2) Supervision of work hours should be increased because of frequent, often underreported lack of compliance with the U.S. accreditation council for graduate medical education (ACGME) limits. The IOM recommends periodic independent reviews of hours worked by residents, as well as increased protections for those who report failure to comply with current work hour restrictions. (3) Moonlighting restrictions should be increased so that both internal and external moonlighting will count against the ACGME 80-hour weekly limit. Only internal moonlighting, defined as additional paid healthcare work at the same healthcare facility, is currently considered part of the 80-hour weekly limit. Because moonlighting outside residency training affects strategically designed periods for rest and sleep and may hinder residents' abilities to complete their primary duties, the IOM recommends that both internal and external moonlighting be counted toward the total work week hourly limit. (4) To facilitate recovery after working long shifts, the IOM recommends a guaranteed 5 days off per month, with 24 hours off each week and one 48-hour period off each month. (5) Hospital on-call periods for residents should be limited to no more than every third night. (6) Because the risk for motor vehicle accidents more than doubles when residents drive home after working extended shifts, hospitals should provide safe transportation to residents who are too fatigued to drive home. (7) Residents should receive more training on better communication, using a structured team approach, during change-of-shift handovers. On the other hand, these handovers will increase as resident shift duration decreases; possibly increasing the risk for adverse events unless training and team communication improve. (8) Residents should be more involved in patient safety activities and in adverse event reporting not only to improve quality of care but also to enhance their educational experience. The recommendations were published on December 2, 2008, in the online issue of the New England Journal of Medicine (NEJM).

"The study provides the clear evidence to prove what we have long-believed is true - fatigue increases the chance for human error," said AHRQ Director Carolyn Clancy, M.D. "Most importantly, this report provides solid recommendations that can improve patient safety, as well as increase the quality of the resident training experience."

Related Links:
Institute of Medicine
Agency for Healthcare Research and Quality