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It's not enough just to reduce residents' hours

A new literature review reveals mixed results for patient safety when work hours are cut.

By Myrle Croasdale, amednews staff. Jan. 17, 2005.

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On the surface, two of the most recent studies looking at the new resident work hour rules in the context of patient safety would seem to be contradictory.

A literature review of studies evaluating the impact of sleep on patient safety, published in the Dec. 7, 2004, Annals of Internal Medicine, found that having residents work fewer hours didn't affect patient mortality.

In contrast, research by the Harvard Work Hours, Health and Safety Study was hailed this fall as the most rigorous proof to date that fatigue is in fact a primary factor behind medical errors.

Kathlyn E. Fletcher, MD, assistant professor of internal medicine at the Medical College of Wisconsin and a clinician-researcher at the VA Medical Center, Milwaukee, led the literature review.

Dr. Fletcher said the apparent contradictions between her work and the landmark Harvard study are more a reflection of the complexity of the issue than of conflicting findings.

"There's been a general perception that by decreasing work hours, by definition we'll be improving patient safety," she said. "This review shows that can happen, but it doesn't always happen. You must do it in a manner that still provides excellent patient care."

The review found seven intervention studies from 1990 to March 2004 that assessed patient safety outcomes in relation to changes made to counteract long work hours, fatigue or sleep deprivation.

Because the Harvard work was published in the Oct. 28, 2004, issue of the New England Journal of Medicine, it was not available when the literature review was conducted. In one study, mortality was unchanged as residents' hours were reduced; in another, patients were more likely to have a complication or test delay when residents' hours were cut.