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Residents' role in reducing medical errors

Residency Program Connection, November 1, 2004

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Dear residency program colleague:

As part of a teaching hospital's program to reduce patient care errors, residents in training should contribute suggestions for improving systems and performance.

In a thoughtful article (Kevin Volpp, MD, PhD and David Grande, MD, "Residents' suggestions for reducing errors in teaching hospitals," NEJM 348.9, February 27, 2003, pp. 851-855), eight such suggestions are made. Some of these suggestions might at first look self-serving, but the suggestions are all relevant to patient safety and quality patient care. Furthermore, the implementation of some of these suggestions costs little, especially in contrast to thousands of dollars spent on consultations, data systems, and maintenance of internal hospital bureaucracies in response to recent public accusations of an unacceptable number of patient care errors in hospitals.

The suggestions include:

 Minimize paging residents. Residents are often distracted from their patient care duties by frequent pages. Consider using e-mail to communicate with residents about "non-urgent" matters. However, keep in mind that residents must be well-oriented and accept responsibility for frequently checking for new e-mail. <LIWrite clear and legible orders. Residents, like physicians, are occasionally confronted by an error that resulted from their illegible handwriting. Some things never change, and are no different in teaching hospitals than in non-teaching hospitals. Use of electronic (computerized) order writing and medical record keeping is helping this problem.

 Provide adequate information when going off duty or leaving patients with a covering resident. Residents complain of being charged with caring for a patient that he or she knows little about-the patient's history and progress notes missing from the chart. In teaching hospitals and non-teaching hospitals alike, careful sign out procedures and clear consultation requests are necessary.

 Allow adequate time for rest when designing duty hours and on call schedules. It is not unusual to hear a resident admit, "Every time I sit down to figure out why Mr. Short's renal function is deteriorating, I fall asleep." The days of using medical students and residents as slave labor in hospitals are long gone. However, the demands of rigorous training, plus the downsizing of a residency program because of limited funds available to support a teaching program, can result in long arduous duty hours. Chances of human error increase with fatigue.

 Ensure ready availability of patient information and needed equipment. When faced with a patient in sudden distress, residents must be able to locate the patient's past records, as well as the equipment he or she needs to care for the patient. Consistent placement of patient records and clinical equipment in all units throughout the hospital will help overcome this obstacle.

 Report errors. Admitting a mistake is difficult in any context. But in residency training, reporting an error is especially difficult because of combined threats of harsh reprimands and malpractice risk. The key is a learning climate that urges learning from one's mistakes, and a reminder that, ironically, upfront honesty with patients about treatment mistakes can lessen the chances that a malpractice claim will be vigorously pursued. Remember, the much needed system corrections will likely not occur if errors are not reported.

 Learn to lead. Today's hospitalized patients are cared for by teams of specialist physicians, nurses, and technicians. Residents should learn early how to exercise the leadership expected of physician members of patient care teams. Good leadership and good communication are two major keys to reducing patient care errors

That's all for this week!

All the best,

Richard E. Thompson, MD
Thompson, Mohr, and Associates, Inc.
Springfield, MO

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