Original Article
Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units
N Engl J Med 2004; 351:1838-1848October 28, 2004DOI: 10.1056/NEJMoa041406
- Abstract
Background
Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.
Methods
We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an “every third night” call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident.
Results
During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001).
Conclusions
Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.
Media in This Article
Figure 1
Representative Work Hours during a Single Week for the Whole Team of Interns during the Traditional Schedule (Panel A) and the Intervention Schedule (Panel B).Table 1
Definitions Used in the Study.Article Activity
- Article
In a pioneering study published in the Journal 33 years ago, Friedman and colleagues reported that interns made almost twice as many errors reading electrocardiograms after an extended (24 hours or more) work shift than after a night of sleep.1 More recent studies have similarly found that surgical residents made up to twice the number of technical errors in the performance of simulated laparoscopic surgical skills after working overnight than after a night of sleep.2,3 Although many prior studies have been methodologically limited by the use of nonvalidated self-reports on the timing of sleep and inadequate accounting for circadian phase and chronic sleep loss, as reviewed elsewhere,4-6 the literature as a whole suggests that sleep deprivation causes substantial decrements in physicians' performance of discrete neurocognitive and simulated clinical tasks.4-8 The clinical importance of sleep curtailment has remained unclear, however,4-6 owing to a lack of studies conducted in clinical care environments4,9 and the possibility that scheduling interventions designed to mitigate sleep deprivation may simultaneously introduce discontinuities in care.10,11
Within hospitals, of all trainees, interns (postgraduate year 1) typically work the greatest number of hours per week.12,13 The extended (24 hours or more) work shifts and long workweeks of interns may make them especially prone to fatigue-induced errors. In a survey of house officers, 41 percent reported fatigue as a cause of their most serious mistake. Most of these events occurred while they were interns, and 31 percent reportedly resulted in fatalities.14
To understand the effects of interns' sleep deprivation on serious medical errors, we conducted a comprehensive comparison of errors while interns followed a traditional work schedule and errors while they followed an intervention work schedule that was designed to reduce sleep deprivation. Our goals were to compare the rates of serious errors directly involving interns on the two schedules, since interns were the focus of our scheduling intervention, and to compare the overall rates of serious medical errors in order to track the effects of interns' schedules on the system as a whole.
Methods
The Intern Sleep and Patient Safety Study was conducted as part of the Harvard Work Hours, Health and Safety Study from July 2002 to June 2003 in the medical intensive care unit (MICU) and coronary care unit (CCU) of Brigham and Women's Hospital, a large academic hospital in Boston, after approval by the institutional review board. The MICU and CCU were selected for study because they are the rotations of this internal-medicine training program with the longest work hours and because medical errors have been detected at higher rates in critical care settings than in other settings.15,16 Both units have 10 adult critical care beds. Data were not collected on patients admitted for fewer than four hours, patients undergoing elective allergy desensitization, or the rare patients who boarded on the units but who were not cared for by the MICU or CCU team.
Design of Intervention Trial
In collaboration with the leadership of the residency program and unit directors, we designed an intervention work schedule for interns that eliminated extended (24 hours or more) work shifts and reduced the number of scheduled hours of work to 63 per week (Figure 1Figure 1
Representative Work Hours during a Single Week for the Whole Team of Interns during the Traditional Schedule (Panel A) and the Intervention Schedule (Panel B).). The traditional MICU house-staff team consisted of three interns and three third-year residents, whereas the CCU team consisted of three interns and two second-year residents. Each intern and resident on these teams worked overnight in the hospital every third night. A resident from another hospital service assumed patient care responsibilities in the CCU on nights when neither of the daytime CCU residents was working. Under this rotation, interns' scheduled workweeks averaged 77 to 81 hours, depending on the clinic assignment, with up to 34 continuous hours of scheduled work when clinic occurred after they were on call (Figure 1A).During the intervention schedule, interns' work hours and overnight work schedules were changed. Interns' traditional extended work shifts were divided in two: a “day-call” intern worked the first half of a traditional call (from 7 a.m. to 10 p.m.); a “night-call” intern worked the second half (from 9 p.m. to 1 p.m. the following day). To effect this schedule, four interns shared patient care responsibilities during the rotation. The maximal scheduled hours of work were 60 to 63 per week, with consecutive hours of work limited to approximately 16 hours (Figure 1B). The intervention did not alter the schedules or staffing of second- or third-year residents or other clinical personnel.
Our goal was to improve interns' opportunities to sleep while minimizing errors due to handoffs of patient care and cross-coverage.10 To minimize cross-coverage errors, we developed a sign-out template for interns to use in all critical care rotations (both intervention and traditional schedules)17 and incorporated an hour of overlap in the evenings for interns on the intervention schedule to sign out formally (see Figure A of the Supplementary Appendix, available with the full text of this article at www.nejm.org) under the supervision of the senior resident.
After providing written informed consent, interns were randomly assigned to work either the intervention schedule in the CCU and the traditional schedule in the MICU or the converse; these rotations were distributed throughout the year. Data collected during a pilot intervention schedule involving four interns that was discontinued after the first ICU rotation were not included. As detailed in the article by Lockley et al. in this issue of the Journal, 18 although actual work hours often exceeded those scheduled during both the traditional and intervention schedules, the intervention successfully eliminated shifts of 24 hours or more, reduced the number of hours worked by interns by nearly 20 per week, increased the average daily duration of sleep by nearly an hour, and reduced attentional failures.
Data Collection and Classification
To measure patients' safety during the two schedules, we developed an intensive system of data collection and evaluation that expanded on methods previously used in the study of medication errors16,19 and also included continuous observation of interns by physicians. In this study, we focused on procedural and diagnostic errors in addition to medication errors. The definitions used to classify incidents are provided in Table 1Table 1
Definitions Used in the Study..A team of two nurse chart reviewers and six physician observers collected data, supplemented by voluntary reports from clinical staff and a computerized event-detection monitor. Direct observation was the principal means of detecting serious errors in which interns were directly involved; physician observers followed study interns continuously, day and night in the hospital. In the afternoons after work rounds, when more than one intern was working simultaneously, only one intern was observed at a time owing to staffing limitations. Residents and other personnel on the units were not directly observed. Data collection for personnel other than interns was less comprehensive and relied on chart review, voluntary reports, and computerized event-detection monitoring. Other methods of data collection, though less comprehensive, were designed to identify all serious medical errors — both those in which interns were involved and those in which they were not involved. Before beginning data collection, all staff received intensive training in the consistent, objective collection of data using standardized forms. Because it was not possible to blind data collectors to the study schedule, determinations of the preventability and classification of events were not made by the primary data collectors. Instead, each suspected error or adverse event identified was independently rated by two physician investigators who were unaware of the identity of those involved or whether the incident occurred during the traditional or intervention schedule.
In the vast majority of cases, the serious errors identified by observers were promptly addressed by medical staff with no need for action on the part of the observers. Nonintercepted serious errors were generally detected by observers when they were discussed by clinical staff. In the handful of cases in which observers identified possible errors in the making with substantial potential to cause harm, they immediately alerted clinical staff to prevent harm to the patient.
Blinded reviewers categorized each incident as an adverse event, nonintercepted serious error, intercepted serious error, or error with little potential for harm (a category that was excluded from the analysis) and rated the preventability of adverse events using a Likert scale (was prevented, was definitely preventable, was probably preventable, was probably not preventable, or was definitely not preventable); the preventability scale was dichotomized to include only “preventable events” and “nonpreventable events” before analysis. Events deemed more likely to be due to patients' underlying illness than to medical therapy were excluded. Disagreements were resolved by discussion; the interrater reliability was calculated before such discussion by means of the kappa statistic, as described below.
Statistical Analysis
Patients' characteristics and the mean daily census of the units during the intervention and traditional rotations were compared by means of Fisher's exact test; Wilcoxon's nonparametric test for dichotomous, nonnormally distributed continuous variables; and a t-test for normally distributed continuous variables. All statistical tests were two-tailed. The rates of diagnostic tests and procedures per patient-day were compared between the two schedules, and the distribution was assumed to be binomial. We compared the rates of medication orders per patient-day between the two schedules, assuming a Poisson distribution, since the presence of rates of more than one order per patient-day precluded the use of the binomial distribution.
We compared the rates of intern-associated serious medical errors per patient-day (for all interns combined) and of total serious medical errors per patient-day between the intervention and traditional schedules, assuming a binomial distribution. The rates of all serious medical errors include all intern-associated serious errors (those detected by direct observation and other methods) plus non–intern-associated errors (identified by chart review, staff reports, and the computerized monitor). We also compared the rates of type-specific errors (medication, procedural, and diagnostic) per patient-day, assuming a binomial distribution. For all tests, two-tailed P values of less than 0.05 were considered to indicate statistical significance.
The study was powered to determine differences in rates of serious medical errors. Analyses of the rates of adverse events were performed, but the results were considered exploratory since we had only 11 percent power to detect a 25 percent difference in intern-associated preventable adverse events. By contrast, the study was designed to have 80 percent power to detect a 16 percent difference in the rate of serious errors between groups.
We evaluated the reliability of the primary data-collection process by conducting dual direct observation for a total of 10 patient-days; there was 82 percent agreement between independent observers with respect to the occurrence of a serious medical error. At the review stage conducted by the blinded investigators, we performed comprehensive reliability testing of all incidents rated using the kappa statistic. For reviewers' judgments about whether an incident was an adverse event, an intercepted serious error, a nonintercepted serious error, or an excluded event, the κ was 0.90; the κ was 0.80 for the preventability of adverse events.
Results
Patient Population
The study involved 2203 patient-days (1294 during the traditional schedule and 909 during the intervention schedule), representing 634 admissions to the units (385 during the traditional schedule and 249 during the intervention schedule) and 5888 hours of direct observation of interns. The patients' characteristics and the units' characteristics were very similar during the traditional and intervention schedules (Table 2Table 2
Characteristics of the Patients and the System.). The number of days included in the traditional schedule exceeded that of the intervention schedule primarily because four interns were required for the intervention schedule as compared with only three for the traditional schedule. Since all interns rotated through both schedules, more traditional than intervention rotations were required to allow each intern to spend three weeks on each schedule. The patients' length of stay and mortality rate did not differ significantly between the two schedules.Serious Medical Errors by Interns
Interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001) (Table 3Table 3
Incidence of Serious Medical Errors.). Interns made 27.8 percent more serious errors that were intercepted during the traditional schedule than during the intervention schedule (70.3 vs. 55.0 per 1000 patient-days, P=0.02) and 56.6 percent more nonintercepted serious errors that reached the patients (44.8 vs. 28.6 per 1000 patient-days, P<0.001). The rates of preventable adverse events did not differ significantly between the two schedules.All Serious Medical Errors and Adverse Events
The rate of all serious medical errors was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001) (Table 3). Intercepted serious errors occurred 37.2 percent more frequently during the traditional schedule than during the intervention schedule (95.1 vs. 69.3 per 1000 patient-days, P<0.001). The overall rates of nonintercepted serious errors did not differ significantly between the two schedules, nor did the rates of preventable adverse events. There was no significant difference in the rates of total adverse events (preventable plus nonpreventable) between the traditional and intervention schedules (85.0 vs. 93.5 per 1000 patient-days, P=0.31). Secondary analysis of the rates of serious medical errors in which interns were not involved revealed no significant differences between the traditional schedule and the intervention schedule (40.2 vs. 38.5 per 1000 patient-days, P=0.69).
Types of Serious Medical Errors
Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001). The rates of serious procedural errors among interns did not differ significantly between the two schedules (Table 3).
Analysis of the types of all errors (errors made by interns plus errors in which interns were not involved) showed similar patterns (Table 3). Serious medication errors occurred 17.1 percent more frequently during the traditional schedule than during the intervention schedule (135.2 vs. 115.5 per 1000 patient-days, P=0.03). The rates of serious procedural errors did not differ significantly between the two schedules. Serious diagnostic errors were nearly twice as common during the traditional schedule as during the intervention schedule (21.6 vs. 11.0 per 1000 patient-days, P<0.001).
Examples of each type of serious medical error and adverse event observed in the study are provided in Table 4Table 4
Examples of Serious Medical Errors and Nonpreventable Adverse Events.. Subcategories of medication and nonmedication errors are available in Table A of the Supplementary Appendix.Discussion
Interns made 36 percent more serious medical errors during a traditional work schedule than during an intervention schedule that eliminated extended work shifts. These included significantly more serious medication errors and 5.6 times as many serious diagnostic errors. As a consequence, the overall rates of serious medical errors were significantly higher during the traditional schedule than during the intervention schedule. Fortunately, most serious medical errors were either intercepted or did not result in clinically detectable harm to the patient. Although the study was not designed to have sufficient statistical power to detect a difference in preventable adverse events, the incidence of intern-associated preventable adverse events was 27 percent higher during the traditional schedule than during the intervention schedule, a difference that was not statistically significant (20.9 vs. 16.5 per 1000 patient-days, P=0.21). The overall rates of preventable adverse events (intern-associated and non–intern-associated) were not significantly different during the traditional and intervention schedules (38.6 and 38.5 per 1000 patient-days, respectively; P=0.91), although our intervention and observations were focused on the interns. This study was not designed or powered to assess comprehensively the effect of the intervention on adverse event rates in the units as a whole. Therefore, it remains to be determined whether the decrease in the rate of serious medical errors by interns will translate into a reduction in the rate of adverse events.
The prospective, randomized nature of this study allowed for a rigorous evaluation of the effects on patients' safety of an intervention designed to improve interns' sleep and thus decrease medical errors. Prior studies using before-and-after cohort designs to assess the effects of scheduling interventions have provided limited and conflicting data. A before-and-after analysis of a scheduling intervention in one hospital that reduced residents' work hours and decreased cross-coverage of unfamiliar patients by senior residents found that the efficiency of care increased and the rates of errors among residents decreased.20 In contrast, an unblinded, retrospective study of a New York State regulation that decreased the number of hours worked by house staff but increased cross-coverage found that the efficiency of care declined and rates of medical complications increased.11 Each was limited by a before-and-after design, which precluded the exclusion of secular trends, increasing experience of house staff, cohort effects, or other external confounders as possible explanations for the changes. Because of concurrent changes in work hours, cross-coverage, and other aspects of care in these studies, it was not possible to identify the elements that may have been responsible for the findings.
The overall incidence of serious errors and adverse events we detected is similar to that reported in other studies of patients' safety in the ICU. For example, Giraud et al.21 and Rubins and Moskowitz22 documented the occurrence of 13 to 40 preventable adverse events per 1000 patient-days. The Harvard Medical Practice Study23 reported lower rates but used a less comprehensive method of data collection and a more restrictive definition of harm, since it sought to detect injuries due to negligence. Donchin et al. reported a higher rate of 1.7 errors per patient-day but included errors with little potential for harm.15 The rates detected by Donchin et al. may also be higher because they focused on errors in the unit as a whole, whereas we directly observed only interns. Moreover, during daytime hours, when two or more interns were working simultaneously in different parts of the units, our staffing limitations allowed us to observe only one intern at a time. Consequently, the true rate of serious errors in the units as a whole may have been higher.
The article by Lockley et al.18 demonstrates that eliminating extended work shifts and reducing the number of hours worked by interns led to significant improvements in interns' sleep and reductions in attentional failures. Although causality cannot be established, it was our a priori hypothesis that increases in sleep resulting from the elimination of extended work shifts and reduction of work hours would lead to a decrease in serious medical errors.24 There were no significant differences between the two schedules in the patients' severity of illness or other individual or systemic variables that could independently account for the observed differences in the rates of medical errors. Our randomized study design greatly diminished the likelihood of hidden confounding owing to secular trends, seasonal effects, learning over the course of the year, or other external factors unrelated to our study.
Before we initiated the intervention schedule, concern was expressed that decreasing the number of hours interns worked might diminish their role in the units, thereby shifting the burden of order writing and procedures and, hence, the risk of errors to more senior staff. Our results did not bear out this concern: the number of medications ordered and tests interpreted by interns per patient-day did not differ significantly between the two schedules, and interns performed significantly more procedures per patient-day during the intervention schedule. Moreover, the error rates among senior residents and other staff members were not increased during the intervention schedule. Thus, the substantially lower rates of errors by interns during the intervention schedule cannot be due to shifting of errors to more senior staff.
The Institute of Medicine's report “To Err Is Human”25 was notably silent regarding the issue of sleep deprivation, largely because data directly linking sleep deprivation and medical error have been lacking. Our study helps to fill this knowledge gap and provides data suggesting that the sleep deprivation associated with the traditional extended shifts of 24 hours or more worked by interns may contribute to the high risk of medical errors in critical care units.
It is important to emphasize that not all interventions that reduce interns' work hours will increase interns' sleep26 or improve patients' safety. Schedule design is a critical factor in determining the extent to which around-the-clock work schedules disrupt wake–sleep cycles, even when the number of weekly work hours remains the same.27 Furthermore, any systemic intervention that reduces work hours necessarily increases either providers' workload (i.e., the number of patients covered by a provider at any time) or the number of handoffs in care between medical personnel on shorter work shifts. Either can lead to increased rates of errors and adverse events.10 “Night-float” systems, which use residents on night shifts to allow physicians working extended work shifts protected time for sleep, have their own set of risks. Night-float residents often know patients less well than do other team members (particularly if multiple residents share responsibilities as night floats over the course of a week, or if night floats are responsible for an increased number of patients), and may themselves be sleep-deprived and error-prone.28 For these reasons, we ultimately decided not to implement a night-float system as a means of reducing interns' work hours, as originally planned.24 Our data support the hypothesis that elimination of extended work shifts in a system that minimizes cross-coverage can improve patients' safety. These gains might not be realized in systems that use extensive cross-coverage.
Although our intervention decreased the rate of serious errors overall, our efforts to optimize the sign-out process were only partially successful. The computerized template was never fully adopted, and the effectiveness of the planned evening sign-out was frequently suboptimal. Although some groups of interns worked successfully as teams and effectively signed out every evening, even in the absence of formal training in team management, others did not. In the latter case, the night-call intern was often unaware of historical details regarding patients admitted by the day-call intern and sometimes performed poorly when describing these patients on morning rounds. This led to a widespread impression that communication on the intervention schedule was problematic, making the improvements in patients' safety we observed all the more remarkable. We suggest that future scheduling interventions address this issue by adding formal evening rounds for the entire team. Such improvements, coupled with the elimination of extended work shifts, could further improve patients' safety.
Our study has several limitations. The intervention schedule improved work hours but still involved shifts that were long enough to induce a number of attentional failures that was greater than would be expected among fully rested people.18 We studied two ICUs in a single hospital, and our results may not be generalizable to other settings. In addition, although our study was very large as compared with prior observational safety studies,15 the study was not powered to detect differences in the rates of preventable adverse events. Larger-scale, multicenter trials are needed to investigate this aspect.
Another important limitation was our inability to blind the medical observers to the schedule of the interns, an issue commonly encountered in investigations of systemic interventions to maximize patients' safety. We addressed this in two ways: first, we instructed observers — none of whom were study investigators — in the importance of consistent, objective detection of serious errors, regardless of study schedule. Second, all initial observations were also reviewed by two independent investigators who were blinded to the study's conditions and who classified incidents with extremely high reliability. Nonetheless, we cannot exclude the possibility that some bias may have resulted from the inability to blind the primary detection process, though our reliability data suggest that this bias was probably minimal.
Notably, our data on the high incidence of intercepted serious errors in ICU settings indicate that the ability of other personnel to act as interns' safety net — nurses, pharmacists, and senior medical staff — is very important in preventing injury to patients as a result of interns' errors. Therefore, future studies should seek to improve and measure objectively the sleep and performance of all clinical unit personnel, since team performance may critically affect patients' safety.29 Having interns on a different schedule than supervising residents may have introduced discontinuities in education and interfered with the traditional resident–intern mentorship bond. We would recommend that future studies investigate the effects of eliminating the extended work shifts of interns and senior residents, both to avoid this problem and because it is unlikely that interns are uniquely susceptible to the adverse effects of sleep deprivation.
Prior interventions that have proved successful in reducing serious medical errors in ICU settings have included the use of computerized provider order entry (CPOE)30 and on-site monitoring of orders by clinical pharmacists.31 The higher intern-associated rate of serious medical errors during the traditional schedule, even in the presence of CPOE, clinical pharmacists, unrestricted use of caffeine by interns,32 and a perceived increase in the risk of handoff errors, indicates the extent of impairment associated with extended work shifts. This observation corroborates the prior experimental finding that a single night of continuous sleep deprivation causes decrements in performance similar to those induced by a blood alcohol level of 0.10 percent.33
By reducing consecutive and weekly work hours, our scheduling intervention attempted to address both acute sleep deprivation and chronic partial sleep deprivation. By reducing interns' sleep deprivation and, hence, depth of subsequent sleep, we also indirectly addressed the adverse effects of sleep inertia (i.e., an increased tendency to err on awakening) on performance, since such impairment is a function of sleep depth.34 The schedule was also designed to attenuate the circadian performance nadir by taking advantage of the blunting of this nadir that occurs when the homeostatic sleep drive is lower.35,36 By providing interns with the opportunity to sleep in the afternoon before working overnight, the schedule thereby muted the effect of circadian misalignment on performance. Medical or surgical simulators could help isolate the effects of these interacting factors, since the relative importance of these variables remains unclear. Strategic use of a novel regimen of caffeine32 or ambient light of specific intensity and wavelengths37,38 may further mitigate the deterioration in performance resulting from circadian misalignment.
In conclusion, the rates of serious medical errors in two ICUs were lowered by eliminating extended work shifts and reducing the number of hours interns worked each week. Our results may have important implications for health policy, since more than 100,000 physicians are currently in training in the United States.39 Most of these residents are regularly scheduled to work 30-hour shifts, since extended work shifts and long workweeks continue to be permitted, even under the scheduling reforms instituted last year by the Accreditation Council for Graduate Medical Education. Further modifications of these standards, particularly with respect to the duration of work shifts, may be needed to improve patients' safety in teaching hospitals nationwide.
Supported by a grant (RO1 HS12032) from the Agency for Healthcare Research and Quality (AHRQ), affording data-confidentiality protection by federal statute (Public Health Service Act 42 U.S.C.); by a grant (RO1 OH07567) from the National Institute for Occupational Safety and Health, which provided a Certificate of Confidentiality for data protection; by the Department of Medicine, Brigham and Women's Hospital; by the Division of Sleep Medicine, Harvard Medical School; by the Brigham and Women's Hospital; and by a General Clinical Research Center grant (M01 RR02635) from the National Center for Research Resources. Dr. Landrigan is the recipient of an AHRQ career development award (K08 HS13333); Dr. Cronin is the recipient of an AHRQ National Research Service Award (F32 HS14130) and a National Heart, Lung, and Blood Institute fellowship in the program of training in Sleep, Circadian, and Respiratory Neurobiology at Brigham and Women's Hospital (T32 HL079010); Dr. Lockley is the recipient of a traveling fellowship from the Wellcome Trust, United Kingdom (060018/B/99/Z); and Dr. Czeisler is supported in part by the National Space Biomedical Research Institute through NASA (NCC 9-58).
We are indebted to our data-collection team, without whom this project could not have occurred; to Patricia Aboagye-Kumi, M.D., Megan Callahan, M.D., Vilma L. Castenada, M.D., Rajneesh S. Hazarika, M.B., B.S., Kristina Martell-Waldrop, R.N., Tamara Sikharulidze, M.D., Noma Rehman, M.D., and Victor Tsveybel, R.N., for their hard work and dedication; to the house staff, attending physicians, nurses, and clinical pharmacists of the CCU and MICU for their ongoing support; to Victor J. Dzau, M.D., Anthony D. Whittemore, M.D., Jeffrey Otten, Matthew Van Vranken, Gary L. Gottlieb, M.D., M.B.A., and Joseph Martin, M.D., Ph.D., for their support and leadership in fostering this study; and to Laura K. Barger, Ph.D., M.P.H., Erin E. Evans, B.S., R.P.S.G.T., Heather L. Gornik, M.D., and DeWitt C. Baldwin, Jr., M.D., for assistance in designing and coordinating the many facets of this effort.
Source Information
From the Divisions of Sleep Medicine (C.P.L., J.W.C., S.W.L., C.A.C.), General Internal Medicine (J.M.R., R.K., E.B., D.W.B.), Infectious Disease (J.T.K.), Pulmonary and Critical Care Medicine (J.W.C., C.M.L.), and Cardiology (P.H.S.) and the Internal Medicine Residency Program (J.T.K.), Department of Medicine, Brigham and Women's Hospital; the Division of Sleep Medicine, Harvard Medical School (C.P.L., J.W.C., S.W.L., C.A.C.); and the Division of General Pediatrics, Department of Medicine, Children's Hospital Boston and Harvard Medical School (C.P.L.) — all in Boston.
Address reprint requests to Dr. Landrigan at the Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, 221 Longwood Ave., Boston, MA 02115, or at [email protected].
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Anders Bech Jørgensen, Ilda Amirian, Sara Kehlet Watt, Thomas Boel, Ismail Gögenur. (2016) No Circadian Variation in Surgeons’ Ability to Diagnose Acute Appendicitis. Journal of Surgical Education 73, 275-280
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François Maltese, Mélanie Adda, Amandine Bablon, Sami Hraeich, Christophe Guervilly, Samuel Lehingue, Sandrine Wiramus, Marc Leone, Claude Martin, Renaud Vialet, Xavier Thirion, Antoine Roch, Jean-Marie Forel, Laurent Papazian. (2016) Night shift decreases cognitive performance of ICU physicians. Intensive Care Medicine 42, 393-400
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Kathlyn E. Fletcher, Siddhartha Singh, Marilyn M. Schapira, Vishal Ratkalkar, Alexis M. Visotcky, Purushottam Laud, Christa Kallio, Susan Framberg, Jianing Li, Andrew Kordus, Jeff Whittle. (2016) Inpatient Housestaff Discontinuity of Care and Patient Adverse Events. The American Journal of Medicine 129, 341-347.e21
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Philip Cheng, Christopher Drake. (2016) Occupational Sleep Medicine. Sleep Medicine Clinics 11, 65-79
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Taryn S. Taylor, Jeff Nisker, Pim W. Teunissen, Tim Dornan, Lorelei Lingard. (2016) Recovery of Sleep or Recovery of Self? A Grounded Theory Study of Residents’ Decision Making Regarding How to Spend Their Nonclinical Postcall Time. Academic Medicine 91, 395-400
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Ning-Zi Sun, Runye Gan, Linda Snell, Diana Dolmans. (2016) Use of a Night Float System to Comply With Resident Duty Hours Restrictions. Academic Medicine 91, 401-408
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Robert W. Bina, G. Michael Lemole, Travis M. Dumont. (2016) On resident duty hour restrictions and neurosurgical training: review of the literature. Journal of Neurosurgery 124, 842-848
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Sofia Fernandes, Ana F. Carvalho, Ana J. Rodrigues, Patrício Costa, Moreno Sanz, Andre Goulart, Hugo Rios, Pedro Leão. (2016) Day and night surgery: is there any influence in the patient postoperative period of urgent colorectal intervention?. International Journal of Colorectal Disease 31, 525-533
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Neelaysh Vukkadala, Andrew Auerbach, Judith H. Maselli, Glenn Rosenbluth. (2016) Association between ordering patterns and shift-based care in general pediatrics inpatients. Journal of Hospital Medicine 11:10.1002/jhm.v11.3, 210-214
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Erin E Flynn-Evans, Laura K Barger, Alan A Kubey, Jason P Sullivan, Charles A Czeisler. (2016) Circadian misalignment affects sleep and medication use before and during spaceflight. npj Microgravity 2, 15019
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Maité Garrouste-Orgeas, Hans Flaatten, Rui Moreno. (2016) Understanding medical errors and adverse events in ICU patients. Intensive Care Medicine 42, 107-109
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Martin N. Stienen, David Netuka, Andreas K. Demetriades, Florian Ringel, Oliver P. Gautschi, Jens Gempt, Dominique Kuhlen, Karl Schaller. (2016) Working time of neurosurgical residents in Europe—results of a multinational survey. Acta Neurochirurgica 158, 17-25
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Henry Lin, Emery Lin, Stephanie Auditore, Jon Fanning. (2016) A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. Academic Medicine 91, 140-150
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J. Chertoff. (2016) Sick number medicine. Internal Medicine Journal 46:10.1111/imj.2016.46.issue-1, 121-122
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Seung-Sup Kim. (2016) Working conditions of interns/residents and patient safety: Painful training might not be authentic. Journal of the Korean Medical Association 59, 82
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William E. Greenberg, Jonathan F. Borus. (2016) The Impact of Resident Duty Hour and Supervision Changes. Harvard Review of Psychiatry 24, 69-76
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Sunny G. Hallowell, Barbara Medoff-Cooper. (2015) Strengthening Israel’s neonatal intensive care nursing workforce. Israel Journal of Health Policy Research 4
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Christopher P. Scally, Andrew M. Ryan, Jyothi R. Thumma, Paul G. Gauger, Justin B. Dimick. (2015) Early impact of the 2011 ACGME duty hour regulations on surgical outcomes. Surgery 158, 1453-1461
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Santosh Patel, Robert Loveridge. (2015) Obstetric Neuraxial Drug Administration Errors. Anesthesia & Analgesia 121, 1570-1577
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Salim Surani, Sean Hesselbacher, Bharat Guntupalli, Sara Surani, Shyam Subramanian. (2015) Sleep Quality and Vigilance Differ Among Inpatient Nurses Based on the Unit Setting and Shift Worked. Journal of Patient Safety 11, 215-220
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KuoJen Tsao, Marybeth Browne. (2015) Culture of safety: A foundation for patient care. Seminars in Pediatric Surgery 24, 283-287
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(2015) Opening the Debate: How to Fulfill the Need for Physicians’ Training in Circadian-Related Topics in a Full Medical School Curriculum. Journal of Circadian Rhythms 13
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Kenan W. Yount, Christine L. Lau, Leora T. Yarboro, Ravi K. Ghanta, Irving L. Kron, John A. Kern, Gorav Ailawadi. (2015) Late Operating Room Start Times Impact Mortality and Cost for Nonemergent Cardiac Surgery. The Annals of Thoracic Surgery 100, 1653-1659
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Audrey Lyndon, Henry C. Lee, Caryl Gay, William M. Gilbert, Jeffrey B. Gould, Kathryn A. Lee. (2015) Effect of time of birth on maternal morbidity during childbirth hospitalization in California. American Journal of Obstetrics and Gynecology 213, 705.e1-705.e11
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Maryam Salari, Vahid Sheibani, Hakimeh Saadati, Alimohammad Pourrahimi, Mohammad khaksarihadad, Khadijeh Esmaeelpour, Mehdi Khodamoradi. (2015) The compensatory effect of regular exercise on long-term memory impairment in sleep deprived female rats. Behavioural Processes 119, 50-57
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Audree B. Condren, Celia M. Divino. (2015) Effect of 2011 Accreditation Council for Graduate Medical Education Duty-Hour Regulations on Objective Measures of Surgical Training. Journal of Surgical Education 72, 855-861
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P. Leveau. (2015) Sicurezza delle cure in medicina di urgenza. EMC - Urgenze 19, 1-8
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Dominique Piquette, Vicki R. LeBlanc. (2015) Five Questions Critical Care Educators Should Ask About Simulation-Based Medical Education. Clinics in Chest Medicine 36, 469-479
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Jason J. Heavner, Jonathan M. Siner. (2015) Adverse Event Reporting and Quality Improvement in the Intensive Care Unit. Clinics in Chest Medicine 36, 461-467
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Robert M. Abrams. (2015) Sleep Deprivation. Obstetrics and Gynecology Clinics of North America 42, 493-506
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Lauren Bolster, Liam Rourke. (2015) The Effect of Restricting Residents' Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review. Journal of Graduate Medical Education 7, 349-363
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R.M. Waeschle, M. Bauer, C.E. Schmidt. (2015) Fehler in der Medizin. Der Anaesthesist 64, 689-704
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Govindarajan, Anand, Urbach, David R., Kumar, Matthew, Li, Qi, Murray, Brian J., Juurlink, David, Kennedy, Erin, Gagliardi, Anna, Sutradhar, Rinku, Baxter, Nancy N., . (2015) Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. New England Journal of Medicine 373:9, 845-853
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Ilda Amirian, Lærke T. Andersen, Jacob Rosenberg, Ismail Gögenur. (2015) Working night shifts affects surgeons' biological rhythm. The American Journal of Surgery 210, 389-395
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D. Cohen, M. Rhydderch, P. Reading, S. Williams. (2015) Doctors’ health: obstacles and enablers to returning to work. Occupational Medicine 65, 459-465
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Hiroshi Nishigori, Gautam A. Deshpande, Haruo Obara, Osamu Takahashi, Jamiu Busari, Tim Dornan. (2015) Beyond work-hour restrictions: a qualitative study of residents’ subjective workload. Perspectives on Medical Education 4, 176-180
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Mohammad Ghasemi, Amir Hossein Khoshakhlagh, Sadrollah Mahmudi, Mohammad Gholami Fesharaki. (2015) Identification and assessment of medical errors in the triage area of an educational hospital using the SHERPA technique in Iran. International Journal of Occupational Safety and Ergonomics 21, 382-390
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Chang Kyun Lee, Jae Myung Cha, Wan Jung Kim. (2015) Endoscopist Fatigue May Contribute to a Decline in the Effectiveness of Screening Colonoscopy. Journal of Clinical Gastroenterology 49, e51-e56
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Clifford B. Saper. (2015) Biology of sleep and circadian rhythms in the neurology resident. Annals of Neurology 78:10.1002/ana.v78.1, 1-2
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Christopher R. Tainter, Nelson L. Wong, Edward A. Bittner. (2015) Innovative strategies in critical care education. Journal of Critical Care 30, 550-556
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Kelly G. Elterman, Lawrence C. Tsen, Chuan-Chin Huang, Michaela K. Farber. (2015) The Influence of a Night-Float Call System on the Incidence of Unintentional Dural Puncture. Anesthesia & Analgesia 120, 1095-1098
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Joel H. Popkin, Khaled Eissa, Kathy Mazor, Celeste Lemay. (2015) The “16 Hour Rule”: a Giant Step, But in Which Direction?. The American Journal of Medicine
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Ju-O Wang, Tzeng-Ji Chen, Senyeong Kao, Te-Chun Yeh, Shung-Tai Ho. (2015) Current status of anesthesia residency in Taiwan: a questionnaire survey. Journal of Anesthesia
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Hannah K. Smalley, Pınar Keskinocak, Atul Vats. (2015) Physician Scheduling for Continuity: An Application in Pediatric Intensive Care. Interfaces 45, 133-148
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Cornelis J. Hopmans, Pieter T. den Hoed, Lijckle van der Laan, Erwin van der Harst, Maarten van der Elst, Guido H.H. Mannaerts, Imro Dawson, Reinier Timman, Bas P.L. Wijnhoven, Jan N.M. IJzermans. (2015) Impact of the European Working Time Directive (EWTD) on the operative experience of surgery residents. Surgery 157, 634-641
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Jonathan A. Ripp, Lisa Bellini, Robert Fallar, Hasan Bazari, Joel T. Katz, Deborah Korenstein. (2015) The Impact of Duty Hours Restrictions on Job Burnout in Internal Medicine Residents. Academic Medicine 90, 494-499
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Jeffrey R. Stowell, Taher T. Vohra, Samuel D. Luber. (2015) Emergency Medicine Resident Clinical Hours: A National Survey. The Journal of Emergency Medicine 48, 474-480.e4
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Eitan Naveh, Tal Katz-Navon, Zvi Stern. (2015) Resident physicians’ clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature. Advances in Health Sciences Education 20, 59-71
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Darko Vucicevic, Farouk Mookadam, Brandon J. Webb, Helene R. Labonte, Stephen S. Cha, Janis E. Blair. (2015) The impact of 2011 ACGME duty hour restrictions on internal medicine resident workload and education. Advances in Health Sciences Education 20, 193-203
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Nessrine Sabri, Ning-Zi Sun, Beth-Ann Cummings, Dev Jayaraman. (2015) The Perceived Effect of Duty Hour Restrictions on Learning Opportunities in the Intensive Care Unit. Journal of Graduate Medical Education 7, 48-52
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Fangyi Gu, Jiali Han, Francine Laden, An Pan, Neil E. Caporaso, Meir J. Stampfer, Ichiro Kawachi, Kathryn M. Rexrode, Walter C. Willett, Susan E. Hankinson, Frank E. Speizer, Eva S. Schernhammer. (2015) Total and Cause-Specific Mortality of U.S. Nurses Working Rotating Night Shifts. American Journal of Preventive Medicine 48, 241-252
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P. Tucker, E. Bejerot, G. Kecklund, G. Aronsson, T. Åkerstedt. (2015) The impact of work time control on physicians' sleep and well-being. Applied Ergonomics 47, 109-116
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Ziv Tsafrir, Joseph Korianski, Benny Almog, Ariel Many, Ory Wiesel, Ishai Levin. (2015) Effects of Fatigue on Residents' Performance in Laparoscopy. Journal of the American College of Surgeons
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Elisa Richter, Valery Blasco, François Antonini, Marc Rey, Laurent Reydellet, Karim Harti, Cyril Nafati, Jacques Albanèse, Marc Leone. (2015) Sleep disorders among French anaesthesiologists and intensivists working in public hospitals. European Journal of Anaesthesiology 32, 132-137
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David W. Cuthbertson, Eric M. Bershad, Haleh Sangi-Haghpeykar, Helen S. Cohen. (2015) Balance as a measurement of fatigue in postcall residents. The Laryngoscope 125:10.1002/lary.v125.2, 337-341
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Anping Xie, Pascale Carayon. (2015) A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. Ergonomics 58, 33-49
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Elena P. Scali, Evgeny Strovski, Bruce B. Forster, Colin Mar, Silvia D. Chang. (2015) Sink or Night Float: University of British Columbia Radiology Residents' Experience With Overnight Call. Canadian Association of Radiologists Journal
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Shelby Harris, Michael Thorpy. . Diagnosis and Treatment of Shift Work Disorder. 2015:, 17-23.
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Joerg Schnoor, Christina Rogalski, Roberto Frontini, Nils Engelmann, Christoph-Eckhardt Heyde. (2015) Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. Patient Safety in Surgery 9, 12
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Yen-ting Chen, Chien-Cheng Huang, Shih-Feng Weng, Chien-Chin Hsu, Jhi-Joung Wang, Hung-Jung Lin, Shih-Bin Su, How-Ran Guo, Chi-Wen Juan. (2015) Acute Myocardial Infarction: A Comparison of the Risk between Physicians and the General Population. BioMed Research International 2015, 1-6
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Yonathan Freund, Alexandra Rousseau, Laurence Berard, Helene Goulet, Patrick Ray, Benjamin Bloom, Tabassome Simon, Bruno Riou. (2015) Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study. BMC Emergency Medicine 15:1
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Giovanni Costa. . Sleep deprivation due to shift work. 2015:, 437-446.
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Su Hyun Oh, Jin Suk Kim, Pyoung Soo Lee. (2015) A survey on training and working conditions of residents in 2015. Journal of the Korean Medical Association 58, 1179
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Herbert D. Aronow, Hitinder S. Gurm, James C. Blankenship, Charles A. Czeisler, Tracy Y. Wang, Lisa A. McCoy, Megan L. Neely, John A. Spertus. (2015) Middle-of-the-Night Percutaneous Coronary Intervention and its Association With Percutaneous Coronary Intervention Outcomes Performed the Following Day. JACC: Cardiovascular Interventions 8, 49-56
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Birgit Harbeck, Sven Suefke, Christian S. Haas, Hendrik Lehnert, Peter Kropp, Heiner Moenig. (2015) No stress after 24-hour on-call shifts?. Journal of Occupational Health 57, 438-447
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Anne Veddeng, Thomas Husby, Ingeborg B. Engelsen, Andrew Kent, Hans Flaatten. (2014) Impact of night shifts on laparoscopic skills and cognitive function among gynecologists. Acta Obstetricia et Gynecologica Scandinavica 93:10.1111/aogs.2014.93.issue-12, 1255-1261
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Starmer , Amy J. , Spector , Nancy D. , Srivastava , Rajendu , West , Daniel C. , Rosenbluth , Glenn , Allen , April D. , Noble , Elizabeth L. , Tse , Lisa L. , Dalal , Anuj K. , Keohane , Carol A. , Lipsitz , Stuart R. , Rothschild , Jeffrey M. , Wien , Matthew F. , Yoon , Catherine S. , Zigmont , Katherine R. , Wilson , Karen M. , O’Toole , Jennifer K. , Solan , Lauren G. , Aylor , Megan , Bismilla , Zia , Coffey , Maitreya , Mahant , Sanjay , Blankenburg , Rebecca L. , Destino , Lauren A. , Everhart , Jennifer L. , Patel , Shilpa J. , Bale , James F. Jr. , Spackman , Jaime B. , Stevenson , Adam T. , Calaman , Sharon , Cole , F. Sessions , Balmer , Dorene F. , Hepps , Jennifer H. , Lopreiato , Joseph O. , Yu , Clifton E. , Sectish , Theodore C. , Landrigan , Christopher P. , . (2014) Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine 371:19, 1803-1812
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O. Schlafer, V. Wenzel, B. Högl. (2014) Schlafstörungen bei Ärzten im Schichtdienst. Der Anaesthesist 63, 844-851
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Daniel J. Schumacher, Mary Pat Frintner, Ariel Winn, William Cull. (2014) Graduating Pediatrics Residents' Reports on the Impact of Fatigue Over the Past Decade of Duty Hour Changes. Academic Pediatrics
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Anupam B. Jena, Jacqueline W. DePasse, Vinay Prasad. (2014) The Declining Demand for Hospital Care as a Rationale for Duty Hour Reform. Journal of General Internal Medicine 29, 1400-1403
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Alan F. Merry, Jennifer Weller, Simon J. Mitchell. (2014) Improving the Quality and Safety of Patient Care in Cardiac Anesthesia. Journal of Cardiothoracic and Vascular Anesthesia 28, 1341-1351
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D.B. Boivin, P. Boudreau. (2014) Impacts of shift work on sleep and circadian rhythms. Pathologie Biologie 62, 292-301
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Ralph G. Dacey. (2014) Editorial: Our continuing experience with duty-hours regulation and its effect on quality of care and education. Journal of Neurosurgery: Spine 21, 499-501
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Jennifer M. Oshimura, Jeffrey Sperring, Benjamin D. Bauer, Aaron E. Carroll, Daniel A. Rauch. (2014) Changes in inpatient staffing following implementation of new residency work hours. Journal of Hospital Medicine 9:10.1002/jhm.v9.10, 640-645
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Richard P. Dutton. (2014) Seamless Anesthesia Care. Anesthesiology 121, 673-674
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Leif Saager, Brian D. Hesler, Jing You, Alparslan Turan, Edward J. Mascha, Daniel I. Sessler, Andrea Kurz. (2014) Intraoperative Transitions of Anesthesia Care and Postoperative Adverse Outcomes. Anesthesiology 121, 695-706
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Joshua Allen-Dicker, Shoshana J. Herzig, Kenneth J. Mukamal, Anjala Tess. (2014) ACGME Duty Hour Revisions and Self-Reported Intern ICU Sleep Schedules. Journal of Graduate Medical Education 6, 561-566
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Mette Munk Lauridsen, Jesper Frøjk, Ove B Schaffalitzky de Muckadell, Hendrik Vilstrup. (2014) Opposite effects of sleep deprivation on the continuous reaction times in patients with liver cirrhosis and normal persons. Metabolic Brain Disease 29, 655-660
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Laura K Barger, Erin E Flynn-Evans, Alan Kubey, Lorcan Walsh, Joseph M Ronda, Wei Wang, Kenneth P Wright, Charles A Czeisler. (2014) Prevalence of sleep deficiency and use of hypnotic drugs in astronauts before, during, and after spaceflight: an observational study. The Lancet Neurology 13, 904-912
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Hannah K. Smalley, Pinar Keskinocak. (2014) Automated medical resident rotation and shift scheduling to ensure quality resident education and patient care. Health Care Management Science
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Dominique Piquette, Maria Mylopoulos, Vicki R LeBlanc. (2014) Clinical supervision and learning opportunities during simulated acute care scenarios. Medical Education 48:10.1111/medu.2014.48.issue-8, 820-830
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Mark Benson, Ian Grimes, Deepak Gopal, Mark Reichelderfer, Anurag Soni, Holly Benson, Kerstin Austin, Patrick Pfau. (2014) Influence of Previous Night Call and Sleep Deprivation on Screening Colonoscopy Quality. The American Journal of Gastroenterology 109, 1133-1137
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Sumedh S. Hoskote, Girish N. Nadkarni, Narender Annapureddy, Aneesha A. Shetty, Ethan D. Fried. (2014) Internal Medicine Residents’ Perspectives on Effects of 2011 ACGME Work Hour Regulations on Patient Care. Teaching and Learning in Medicine 26, 274-278
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Erika K. Cottrell, Kerth O'Brien, Merlin Curry, Garth D. Meckler, Philip P. Engle, Jonathan Jui, Caitlin Summers, William Lambert, Jeanne-Marie Guise. (2014) Understanding Safety in Prehospital Emergency Medical Services for Children. Prehospital Emergency Care 18, 350-358
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Andrew D. Van Osdol, Colette T. O’Heron, Benjamin T. Jarman. (2014) “Same as It Ever Was”—Only Different: A Successful ACGME Innovative Project to Equip PGY I Residents to Take At-Home Call. Journal of Surgical Education
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Kanwal Kumar, Rohit Singal, Rizwan A. Manji, Ryan Zarychanski, Dean D. Bell, Darren H. Freed, Rakesh C. Arora. (2014) The benefits of 24/7 in-house intensivist coverage for prolonged-stay cardiac surgery patients. The Journal of Thoracic and Cardiovascular Surgery 148, 290-297.e6
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P. E. Wu, L. Stroud, H. McDonald-Blumer, B. M. Wong. (2014) Understanding the effect of resident duty hour reform: a qualitative study. CMAJ Open 2, E115-E120
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Saadi Taher, Fayez Hejaili, Ayman Karkar, Faissal Shaheen, Majdah Barahmien, Khalid Al Saran, Mohamed Jondeby, Mohamed Suleiman, Abdulla Ahmed Al Sayyari. (2014) Safety Climate in Dialysis Centers in Saudi Arabia. Journal of Patient Safety 10, 101-104
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Svenja Kockert, Thomas Schott. (2014) Organisation und Versorgungsqualität. Public Health Forum 22, 7.e1-7.e3
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Lauren Block, Marian Jarlenski, Albert W. Wu, Leonard Feldman, Joseph Conigliaro, Jenna Swann, Sanjay V. Desai. (2014) Inpatient safety outcomes following the 2011 residency work-hour reform. Journal of Hospital Medicine 9:10.1002/jhm.v9.6, 347-352
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Sébastien Lachance, Jean-François Latulippe, Luc Valiquette, Gaétan Langlois, Yvan Douville, Gerald M. Fried, Carole Richard. (2014) Perceived Effects of the 16-Hour Workday Restriction on Surgical Specialties: Quebec’s Experience. Journal of Surgical Education
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Duygu Yazgan Aksoy, Mine Durusu Tanriover, Sule Unal, Omer Dizdar, Umut Kalyoncu, Jale Karakaya, Serhat Unal, Gulsev Kale. (2014) Burnout syndrome during residency in internal medicine and pediatrics in a country without working time directive. International Journal of Health Care Quality Assurance 27, 223-230
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Masaya Takahashi. (2014) Assisting shift workers through sleep and circadian research. Sleep and Biological Rhythms 12:10.1111/sbr.2014.12.issue-2, 85-95
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Jeffrey H. Silber, Patrick S. Romano, Kamal M.F. Itani, Amy K. Rosen, Dylan Small, Rebecca S. Lipner, Charles L. Bosk, Yanli Wang, Michael J. Halenar, Sophia Korovaichuk, Orit Even-Shoshan, Kevin G. Volpp. (2014) Assessing the Effects of the 2003 Resident Duty Hours Reform on Internal Medicine Board Scores. Academic Medicine 89, 644-651
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Joshua M. Tobin. (2014) Developing a trauma curriculum for anesthesiology residents and fellows. Current Opinion in Anaesthesiology 27, 240-245
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Adam Moreton, Emma Jackson, Yasmin Ahmed-Little. (2014) Learning the lessons from banding appeals. Journal of Health Organization and Management 28, 62-76
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Daniel J. Schumacher, Mary Pat Frintner, Anuja Jain, William Cull. (2014) The 2011 ACGME Standards: Impact Reported by Graduating Residents on the Working and Learning Environment. Academic Pediatrics 14, 149-154
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Pooyan Kazemian, Yue Dong, Thomas R. Rohleder, Jonathan E. Helm, Mark P. Van Oyen. (2014) An IP-based healthcare provider shift design approach to minimize patient handoffs. Health Care Management Science 17, 1-14
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Rachel Lawrence, Ira Kantrowitz-Gordon, Andrea Landis. (2014) Student Midwives’ Duty Hours: Risks, Standards, and Recommendations. Journal of Midwifery & Women's Health 59:10.1111/jmwh.2014.59.issue-2, 127-140
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J. Schreiber, S. Hart, L. Hart, S. Arshad. (2014) Program Directors' View of Duty Hours: Where Do We Go From Here?. AAP Grand Rounds 31, 32-32
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Imogen Goold, Hannah Maslen. (2014) Must the Surgeon Take the Pill? Negligence Duty in the Context of Cognitive Enhancement. The Modern Law Review 77:10.1111/mlr.2014.77.issue-1, 60-86
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Nawfal Doghmi, Salaheddine Massou, Hicham Balkhi, Cherqui Haimeur, Nordine Drissi Kamili. (2013) Le burn out, conséquences et solutions : enquête chez les personnels d’anesthésie–réanimation de quatre hôpitaux universitaires marocains. Annales Médico-psychologiques, revue psychiatrique 171, 700-704
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Dominique Piquette, Jordan Tarshis, Glenn Regehr, Robert A. Fowler, Ruxandra Pinto, Vicki R. LeBlanc. (2013) Effects of Clinical Supervision on Resident Learning and Patient Care During Simulated ICU Scenarios*. Critical Care Medicine 41, 2705-2711
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