Lack of supervision adds to resident errors, study finds

A review of 240 medical liability cases tied 70% of such errors to not enough attending oversight.

By Myrle Croasdale — Posted Nov. 26, 2007

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Residents are vulnerable to making errors that stem from teamwork breakdowns, especially a lack of attending supervision, according to a study in the Oct. 22 Archives of Internal Medicine.

In response, some experts said residencies should focus on better supervision, along with improved team communications. One went so far as to call for a new model of resident training and patient care. Others disagreed, saying residencies had improved such issues since the study's data were compiled and did not need significant restructuring.

Hardeep Singh, MD, MPH, lead study author, is among those who believe improvements in resident supervision are in order.

"It's important that resident programs pay attention to supervision and teamwork issues even more than before," said Dr. Singh, an internist with the Dept. of Veterans Affairs in Houston and an assistant professor at Baylor College of Medicine.

Out of 889 medical liability claims reviewed, Dr. Singh and his colleagues found 240 claims where residents played a part in serious patient injuries or deaths.

Resident errors tied to teamwork-related factors, particularly attending physician supervision failures, took place in 70% of the cases that were reviewed.

In 72% of cases, judgment errors, such as failures of memory or vigilance, were a factor. In 58%, a lack of technical competence or knowledge, such as residents' diagnosis or patient monitoring, was involved.

All of the lawsuits were closed, and the errors occurred between 1979 and 2001. In 2003, resident work-hour limits were imposed, a change that dramatically restructured many medical residencies.

Dr. Singh said safety improvements garnered from the reduction in hours and a decrease in residents' work loads were offset by an increase in patient handoffs. Instead of making the study's findings less relevant, he said, these changes amplified the need for better supervision and team communication.

Dr. Singh said the data's quality reviewed for the study added to its impact. Researchers examined patient records and other items contained in medical liability claims. Most resident error studies rely on residents' or other physicians' perceptions of errors made, which are collected through interviews or surveys, not detailed legal documents.

Finding a fix

Improving residents' medical knowledge and their technical expertise to sharpen both their judgment and technical competence would fix two of the three leading contributors to medical errors, educators said, and addressing these two issues is straightforward. But increasing attendings' supervision of residents is more complex. Autonomy is a critical part of training, and too much supervision could impede a resident's development.

"There's a balance between supervision and autonomy," said Keith B. Armitage, MD, president of the Assn. of Program Directors in Internal Medicine. "You can't learn without some autonomy."

During the '80s and '90s, when most of the errors reviewed in the study occurred, residents had much less supervision than they have today, said Dr. Armitage, who is also internal medicine residency director at Case Western Reserve University in Cleveland. He does not see a need to increase resident oversight.

Lisa Bellini, MD, chair of an APDIM's task force on improving the resident learning environment, said that in the past four or five years, there has been a broader adoption of electronic medical records and an effort to standardize patient handoffs -- both initiatives that improve communication and reduce errors.

"Communication is better than it has ever been before in resident training," said Dr. Bellini, who is also vice chair for education and inpatient services for the Dept. of Medicine at the University of Pennsylvania School of Medicine in Philadelphia. "What this study tells us is that we are not wasting our time focusing on handoffs and interdisciplinary communication and creating standardized tools for this communication."

More efforts needed

Robert A. Phillips, MD, PhD, the director of the Heart and Vascular Center of Excellence at the University of Massachusetts Memorial Medical Center in Worcester, wrote an editorial on the study. He said such efforts were beneficial, but they are not enough.

He would like to see a model of care centered around a hospitalist, with the team's players, such as residents, nurses, social workers and pharmacists, working the same hours, instead of a string of players rotating in and out of the team on separate schedules.

"This is going to constitute a radical shift," Dr. Phillips said of the model he hopes to pilot in the next year or two. "It's going to tie performance and coordination of care to pay."

The incentive for this model would be higher reimbursements. A patient's care given by the same resident or nurse day after day would earn a higher score than care given by a constantly rotating cast of health care professionals.

Dr. Phillips expects this model to decrease patient errors dramatically, and he anticipates that it will increase job satisfaction among physicians and other team members, while at the same time improving the teaching environment.

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Mistakes residents make

In the Oct. 22 Archives of Internal Medicine, researchers examined 240 medical liability cases where residents' mistakes were a factor in a patient's death or injury; then they categorized the types of errors made.

Here are some of the top contributing factors in resident errors:

Contributing factor Errors contributed to
Judgment error 173 (72% of cases examined)
Memory or vigilance error 137 (57% of cases)
Lack of technical competence or knowledge 139 (58% of cases)
Lack of supervision 129 (54% of cases)
Handoff problems 46 (19% of cases
Excessive workload 46 (19% of cases)

Note: Multiple factors could be present when an error was made.

Source: "Medical Errors Involving Trainees," Archives of Internal Medicine, Oct. 22

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