Effects of the Accreditation Council for Graduate Medical Education Duty-Hour Limits on Sleep, Work Hours, and Safety

Abstract

To the Editor.—After introduction of the Accreditation Council for Graduate Medical Education resident duty-hour restrictions in 2003, many voiced concerns about an increased number of handoffs, during which patient care responsibility is transferred from 1 resident who is leaving the hospital to another resident who will be staying and covering other residents’ patients.1,2 In a survey of accredited US internal medicine residency programs, handoffs did, in fact, increase significantly after duty-hour restrictions, and a member of the primary health care team was present in the hospital for less than half of a patient's hospitalization.3 This highlights the importance of addressing handoffs in conjunction with restricted duty hours.In a recent Pediatrics article by Landrigan et al,4 there was no significant change found in the total hours of work or sleep before and after duty-hour restrictions were implemented. Although there was no change in overall medication error rates, there was a significant increase in errors that the authors classified as having little potential for harm and a trend toward an increase in physician ordering errors. As the authors suggested, this may have been a result of the increased handoffs without a corresponding increase in handoff education and improvement.It is important to acknowledge that each time a handoff occurs, the possibility for miscommunication arises. Handoffs have been characterized as having omitted or inaccurate information that could be critical to patient care, which can compromise patient care.5 Therefore, undertaking formal handoff education and improvement activities is critical for ensuring safe patient care with restricted resident duty hours. Although the Joint Commission has made “a standardized approach” to handoffs part of its national patient safety goals, it is unclear if pediatric residents receive formal handoff training and evaluation. Unfortunately, there is little literature to guide pediatric educators who are seeking to improve handoff education and monitoring.At the University of Chicago, we have been studying the safety and integrity of resident handoffs through social science frameworks. For example, communication psychologists have demonstrated that senders often overestimate how well their messages are understood by receivers as a result of a framing bias.6 On the basis of this framework, we are currently examining the effectiveness of handoff communication between our pediatric interns to design an intervention to improve handoff communication. It is imperative that researchers and educators undertake formal handoff education and improvement efforts, especially in the face of potential further reductions in duty-hour limits.