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Hospital Shifts and Medical Mistakes

Without a doubt, the best way of dealing with hospital errors is to prevent them from happening in the first place. In a recent on-line Globe and Mail article, Attempt to shorten shifts for doctors causing unintended consequences, correspondent Lee Marshall identified a new potential source of medical errors. According to Ms. Marshall, this new problem grew out of the well-intended need to shorten the ridiculously long shifts that many hospital workers, principally medical residents, traditionally have had to tolerate. In a recent survey of their members conducted by The Canadian Association of Internes and Residents, it was reported that their members worked an average of 62.6 hours per week, and slept an average of 3.2 hours per day while on call. The worst case seems to be in the specialty in which one might expect a need for the greatest acuity, surgical residents, who reported working slightly more than 75 hours per week and an average of 20.2 consecutive in-house duty hours.

Anyone who has endured the rigours of medical residency will ask, "What's wrong with that?" The answer can be found in a 1997 research paper titled, Fatigue, alcohol and performance impairment, by Drew Dawson and Kathryn Reid, published in Nature: Weekly International Journal of Science. In that paper the authors noted that,

". . . after 17 hours of sustained wakefulness cognitive psychomotor performance decreased to a level equivalent to the performance impairment observed at a blood alcohol concentration of 0.05%. . . . After 24 hours of sustained wakefulness cognitive psychomotor performance decreased to a level equivalent to the performance deficit observed at a blood alcohol concentration of roughly 0.10%."

In British Columbia if car drivers are found to have blood alcohol concentrations of .05% they can be served with an immediate roadside prohibition and have their cars impounded. Behavioural characteristics associated with blood alcohol concentrations between .06% and .10% include: impaired judgment, impaired coordination, diminished of sense of hearing and vision, and slowed mental processing. One can't help but wonder how a person would feel about being operated on by a physician who displays these behaviours.

In her article Ms. Marshall points out that the problems associated with working very long hours has been understood for years and that as a result many hospitals have made efforts to regulate the maximum permissible hours of work. She notes that in 2011 the Province of Quebec mandated the maximum continuous hours of work for medical residents to be not greater than 16 hours per day. Whereas intuitively one might expect that these actions ought to result in fewer medical errors, the article suggests that isn't necessarily the case. In fact Ms. Marshall cites researchers who claim that the moves to regulate shorter shifts have made the situation worse, not better.

The culprit here is poor documentation and communication during the process of handing over patient care from an outgoing hospital shift to their incoming colleagues. In the simplest terms, critical patient information is missing or inaccurate and poorly documented when it exists. The article suggests that if poor patient handover practices are the source of many medical errors then the more often shifts change, the greater the risk of those medical errors. Efforts to impose shorter hours of work have resulted in the need to turn over staff more frequently resulting in more patient hand-overs and a greater incidence of errors being made.

In our experience, this sort of problem is not uncommon. Here's a scenario that combines a number of issues we commonly see:

A 50 year old man attended the emergency room of a small community hospital with severe back pain that had been getting worse over the past week. He had not been able to sleep and was having chills. His back pain extended to the rib area. He was in so much pain he could not lay still for assessments. He was admitted to the hospital, and over the first 4 days was seen by a different doctor every day. His situation worsened and over the following days the nurses noted that he was having difficulty urinating and was developing leg weakness and numbness. After suffering this way for 7 days he finally had an MRI which showed a mass on his spine; he was diagnosed with a spinal epidural abscess which required immediate surgical decompression and long-term antibiotic therapy. As a result of his spinal epidural abscess he suffered a severe spinal cord injury and is now paraplegic.

The question is; did the frequent hand-overs between four different doctors over four days cause a lack of continuity which negatively impacted this patient's ability to get a timely diagnosis and treatment?

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