Graduate medical education and patient safety: A busy - and occasionally hazardous - intersection

Annals of Internal Medicine

Volumn 145, Issue 8, 2006, Pages 592-598

  Shojania, Kaveh G ^a,b   Fletcher, Kathlyn E ^c   Saint, Sanjay ^d  

^a UNIVERSITY OF OTTAWA   (Canada)

^b OTTAWA HOSPITAL RESEARCH INSTITUTE   (Canada)

^c MEDICAL COLLEGE OF WISCONSIN   (United States)

^d NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACUTE PANCREATITIS; AGED; ANGINA PECTORIS; ARTICLE; CASE REPORT; COMMUNICATION SKILL; FEEDING APPARATUS; FEMALE; HOSPITAL ADMISSION; HUMAN; HYPERTENSION; INTRAVENOUS ADMINISTRATION; MEDICAL EDUCATION; MEDICAL STUDENT; NASOGASTRIC TUBE; PATIENT SAFETY; PHYSICIAN; PRIORITY JOURNAL; TEACHING HOSPITAL; CLINICAL OBSERVATION; CLINICAL STUDY; DIAGNOSIS; INTERPERSONAL COMMUNICATION; MEDICAL ERROR; ORGANIZATION AND MANAGEMENT; PATIENT CARE; STANDARD;

AGED, 80 AND OVER; COMMUNICATION; EDUCATION, MEDICAL, GRADUATE; FEMALE; HOSPITALS, TEACHING; HUMANS; INTERNSHIP AND RESIDENCY; MEDICAL ERRORS; PATIENT CARE; PATIENT CARE TEAM;

EID: 33750716860     PISSN: 00034819     EISSN: None     Source Type: Journal    
DOI: 10.7326/0003-4819-145-8-200610170-00008     Document Type: Article

References (41)

1. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115-20.
2. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-80.
3. Barry WA, Rosenthal GE. Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med. 2003;18:639-45.
4. Claridge JA, Schulman AM, Sawyer RG, Ghezel-Ayagh A, Young JS. The "July phenomenon" and the care of the severely injured patient: fact or fiction? Surgery. 2001;130:346-53.
5. Buchwald D, Komaroff AL, Cook EF, Epstein AM. Indirect costs for medical education. Is there a July phenomenon? Arch Intern Med. 1989;149:765-8.
6. Borenstein SH, Choi M, Gerstle JT, Langer JC. Errors and adverse outcomes on a surgical service: what is the role of residents? J Surg Res. 2004;122:162-6.
7. Shulkin DJ. The July phenomenon revisited: are hospital complications associated with new house staff? Am J Med Qual. 1995;10:14-7.
8. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001;345:663-8.
9. Cram P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med. 2004;117:151-7.
10. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866-72.
11. Shojania KG, Wald H, Gross R. Understanding medical error and improving patient safety in the inpatient setting. Med Clin North Am. 2002;86:847-67.
12. Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77-87.
13. Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200:538-45.
14. Astion M, Chou D. Notifying Physicians about Laboratory Data: Pushing and Pulling with the Help of a Sympathetic Laboratory. Lab Errors Patient Safety. 2005;1:2-5. Accessed at www.laboratoryerrors.org/archives.aspx on 18 August 2006.
15. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-94.
16. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-7.
17. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32:167-75.
18. Joint Commission on Accreditation of Healthcare Organizations. 2006 National Patient Safety Goals. Goal 2 (Communication). Accessed at www.joint commission.org/NR/rdonlyres/25E48E23-6946-43E4-916C-65E116960FD5/0/ 06_npsg_faq2.pdf on 7 July 2006.
19. Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004;121:801-3.
20. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ. 2000;34:827-40.
21. Phy MP, Offord KP, Manning DM, Bundrick JB, Huddleston JM. Increased faculty presence on inpatient teaching services. Mayo Clin Proc. 2004;79:332-6.
22. Leach DC. Supervision: nine helpful principles and a story. ACGME Bulletin. 2005:2-3. Accessed at www.va.gov/oaa/Archive/ACGME_Bulletin09_05.pdf on 18 August 2006.
23. Flynn T. Resident supervision. ACGME Bulletin. 2005:15-7. Accessed at www.va.gov/oaa/Archive/ACGME_Bulletin09_05.pdf on 7 July 2006.
24. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826-33.
25. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137:327-33.
26. Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138:33-9.
27. Reason J. Human error: models and management. BMJ. 2000;320:768-70.
28. Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000;320:777-81.
29. Smith L. One dose, fifty pills. AHRQ Web M&M [Serial Online]. 2005 November. http://webmm.ahrq.gov/case.aspx?caseID=109 on 7 July 2006.
30. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745-9.
31. Ofri D. Residency regulations - resisting our reflexes. N Engl J Med. 2004;351:1824-6.
32. Fletcher KE, UnderwoodW3rd, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S. Effects of work hour reduction on residents' lives: a systematic review. JAMA. 2005;294:1088-100.
33. Zaré SM, Galanko JA, Behrns KE, Sieff EM, Boyle LM, Farley DR, et al. Psychologic well-being of surgery residents after inception of the 80-hour workweek: a multi-institutional study. Surgery. 2005;138:150-7.
34. Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF Jr, Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med. 2004;141:851-7.
35. Ryan J. Unintended consequences: the Accreditation Council for Graduate Medical Education work-hour rules in practice. Ann Intern Med. 2005;143:82-3.
36. Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA. 1993;269:374-8.
37. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290:2838-42.
38. Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf. 2003;29:503-11.
39. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-94.
40. Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B, Riviello R. The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration. Acad Med. 2005;80:758-64.
41. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too [Editorial]. BMJ. 2000;320:726-7.