In the Literature: March 2010

The Hospitalist. 2010 March;2010(03):

March 1, 2010 | The Hospitalist

Resident Fatigue and Distress Contribute to Perceived Medical Errors

Clinical question: Do resident fatigue and distress contribute to medical errors?

Background: In recent years, such measures as work-hour limitations have been implemented to decrease resident fatigue and, it is presumed, medical errors. However, few studies address the relationship between residents’ well-being and self-reported medical errors.

Study design: Prospective six-year longitudinal cohort study.

Setting: Single academic medical center.

Synopsis: The authors had 380 internal-medicine residents complete quarterly surveys to assess fatigue, quality of life, burnout, symptoms of depression, and frequency of perceived medical errors. In a univariate analysis, fatigue/sleepiness, burnout, depression, and overall quality of life measures correlated significantly with self-reported major medical errors. Fatigue/sleepiness and measures of distress additively increased the risk of self-reported errors. Increases in one or both domains were estimated to increase the risk of self-reported errors by as much as 15% to 28%.

The authors studied only self-reported medical errors. It is difficult to know whether these errors directly affected patient outcomes. Additionally, results of this single-site study might not be able to be generalized.

Bottom line: Fatigue and distress contribute to self-perceived medical errors among residents.

Citation: West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300.

Clinical Shorts

EARLY DEFIBRILLATOR IMPLANTATION DOES NOT REDUCE MORTALITY IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Randomized trial of patients with acute MI and clinical risks revealed no net survival benefit with early ICD. Sudden cardiac death reduction was offset by an increase in non-sudden death.

Citation: Steinbeck G, Andresen D, Seidl K, et al. Defibrillator implantation early after myocardial infarction. N Engl J Med. 2009;361(15):1427-1436.

in-HOSPITAL DIALYSIS FOR ACUTE KIDNEY INJURY INCREASES RISK OF CHRONIC DIALYSIS BUT NOT DEATH

Retrospective cohort study demonstrated that chronic dialysis was three times more likely among survivors of acute kidney injury requiring inpatient dialysis. Mortality risk was not increased within three-year followup.

Citation: Wald R, Quinn RR, Luo J, et al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA. 2009;302(11):1179-1185.

ATTENDING PHYSICIAN SLEEP DEPRIVATION RESULTS IN INCREASED PROCEDURAL COMPLICATIONS

In this matched retrospective cohort study, attending surgeons and OB-GYNs with less than six hours of sleep because of clinical duties had an increased complication rate during procedures performed the following day.

Citation: Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565-1572.

NICOTINE PATCH PLUS NICOTINE LOZENGES ARE CORRELATED WITH HIGHEST SMOKING ABSTINENCE RATES

A randomized, double-blind, placebo-controlled trial of 1,504 adult smokers showed that the nicotine patch plus lozenges resulted in significantly higher abstinence (OR 2.34) than placebo, nicotine replacement, or sustained-release bupropion.

Citation: Piper ME, Smith SS, Schlam TR, et al. A randomized placebo-controlled clinical trial of 5 smoking cessation pharmacotherapies. Arch Gen Psychiatry. 2009; 66(11):1253-1262.

Inhaled Corticosteroids Decrease Inflammation in Moderate to Severe COPD

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.