Effect on patient safety of a resident physician schedule without 24-hour shifts
Open accessAbstract
BACKGROUND: The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial. METHODS: We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review. RESULTS: The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P<0.001). The number of serious errors unitwide were likewise higher during the intervention schedules (181.3 vs. 131.5 per 1000 patient-days; relative risk, 1.56; 95% CI, 1.43 to 1.71). There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors. CONCLUSIONS: Contrary to our hypothesis, resident physicians who were randomly assigned to schedules that eliminated extended shifts made more serious errors than resident physicians assigned to schedules with extended shifts, although the effect varied by site. The number of ICU patients cared for by each resident physician was higher during schedules that eliminated extended shifts. (Funded by the National Heart, Lung, and Blood Institute; ROSTERS ClinicalTrials.gov number, NCT02134847.).
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Heterogeneous management of ICU-ward transitions may affect hospital quality and safety.
“ICU–ward transitions are managed heterogeneously across health systems (1), which may affect hospital quality and safety (3).”
From Cocreating the ICU-PAUSE Tool for Intensive Care Unit–Ward Transitions (2022) · cites this paper as [3]
The Discussion says poor handoffs can degrade patient safety and suggests that handoff processes may have contributed to differences in safety outcomes across sites. But the study concerns handoffs between resident shifts in pediatric ICUs, not ICU-to-ward transitions, and does not assess hospital quality as a separate outcome. (LLM, conf=0.85)
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- Authors
- Landrigan, C. P., Rahman, S. A., Sullivan, J. P., Vittinghoff, E., Barger, L. K., Sanderson, A. L., Wright, K. P., O’Brien, C. S., Qadri, S., St. Hilaire, M. A., Halbower, A. C., Segar, J. L., McGuire, J. K., Vitiello, M. V., de la Iglesia, H. O., Poynter, S. E., Yu, P. L., Zee, P. C., Lockley, S. W., Stone, K. L., & Czeisler, C. A.
- Affiliations
- Brigham and Women's Hospital (US)
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston...
- Northwestern University (US)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2020-06-25
- Volume
- 382
- Issue
- 26
- Pages
- 2514-2523
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC7405505
- OpenAlex
- W3037054638
- Cited by
- 105
- References
- 34
- Citations by year
- 2026: 13 · 2025: 16 · 2024: 20 · 2023: 13 · 2022: 18 · 2021: 18 · 2020: 6
- FWCI
- 13.24
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Surrey Research Insight Open Access (The University of Surrey) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute for Occupational Safety and Health (R01-OH-010300)
- National Heart, Lung, and Blood Institute (K24-HL-105664, R01-HL-114088, R01-HL-128538, U01-HL-111478, U01-HL-111691)
- National Institute of General Medical Sciences (R01-GM-105018)
- National Institute of Child Health and Human Development (R21-HD-086392)
- National Institute on Aging (P01-AG-009975)
- National Space Biomedical Research Institute (HFP-0006, HFP-02802, HFP-04201)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and Work-Related Fatigue
- Keywords
- 24-hour shifts, patient safety, pediatric residents, resident workload, shift length
- MeSH terms
- Humans, Internship and Residency, Personnel Staffing and Scheduling, Psychomotor Performance, Sleep, Time Factors, Work Schedule Tolerance, Intensive Care Units, Pediatric, Workload, Cross-Over Studies, Medical Errors, Patient Safety
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