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Preventing physician fatigue


A group of 26 of the nation’s leaders in medicine, health care, patient safety, and research recently called for sweeping changes in the design, supervision, and financing of U.S. hospital residency care programs to protect patients from serious, preventable medical errors, and end dangerously long work hours for physicians in training.

In a set of recommendations published in the June 24 issue of the online journal Nature & Science of Sleep, the authors say the rules for residency training set to take effect on July 1 “stop considerably short” of best practices to ensure patient safety, and they call on hospital administrators and residency program directors to go much further to keep health care safe.

The report examining residency work hours, supervision, and safety is the product of a conference held last June at Harvard Medical School. The conference was convened to develop a road map for implementation of the Institute of Medicine (IOM) recommendations for residency reform published in 2009. The IOM report called for major changes in residency training programs, including eliminating shifts exceeding 16 hours without sleep for all resident physicians, but those recommendations have yet to be implemented.

“The current system amounts to an abuse of patient trust,” says Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and a co-author of the report. “Few people enter a hospital expecting that their care and safety are in the hands of someone who has been working a double shift or more with no sleep. If they knew, and had a choice, the overwhelming majority would demand another doctor or leave.”

Research shows that resident fatigue is a major contributor to the millions of medical errors that occur each year in the nation’s hospitals. In April, a study in the journal Health Affairs showed that despite more than a decade of national focus on patient safety, medical errors occur as much as 10 times more than some previous estimates have indicated. A 2010 report from the HHS Inspector General’s Office revealed that as many as 180,000 patients die each year due to harm resulting from medical care.

Christopher Landrigan, MD, MPH, a co-author of the Harvard report and lead author of the recent and widely cited “North Carolina Patient Safety Study,” says rates of harm due to medical error have been relatively constant. “Adoption of even the best proven interventions to reduce medical errors – including elimination of shifts exceeding 16 consecutive hours for resident physicians – has been extremely poor.”

Besides resident physician fatigue, the Harvard recommendations cover six other areas: workload and supervision; moonlighting; resident physician safety; hand-over practices and training in quality improvement; monitoring and oversight of the Accreditation Council for Graduate Medical Education (ACGME), the body that oversees residency programs; and funding for reform implementation

Key recommendations include the following:

  • Limiting all resident physician work hours to shifts of 12 to 16 hours.
  • Making ACGME work-hour compliance a condition of participation for Medicare graduate medical education (GME) support.
  • Identifying in real time when a resident physician’s workload is excessive and additional staff should be activated.
  • Requiring attending physicians to supervise all hospital admissions.
  • Mandating in-house supervision for all critical care services, including emergency, intensive care, and trauma services.
  • Making comprehensive fatigue management a Joint Commission National Patient Safety Goal. The recommendations note that “fatigue is a safety concern not only for resident physicians, but for nurses, attending physicians and other health care workers.”

“Implementing the 2009 Institute of Medicine Recommendations on Resident Physician Work Hours, Supervision, and Safety: Report from a Conference at Harvard Medical School,” is available from the Nature and Science of Sleep Journal’s website at


  • This has been a problem that physicians have been dealing with since time began. Physicians have the mind set that since “I did it, I have the right and obligation to make everyone else do it” (Work excessive hours)I have propped up interns and residents and worried about how they could possibly drive home without crashing. It wasn’t safe then and isn’t safe now. Now we’ve extended it to nurses who would rather would long hours “just to get it over with”. It isn’t safe and it isn’t professional.

  • WE have been reading the recommendations to reduce resident fatigue – great – but I would also be most interested in how to reduce nurse fatigure when nurses work long hours for one employer and the work added hours for another. One nurse I know works 40 hours and then teaches at least 24 hours more -what are the recommendations for reducing nurse fatigue

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