If you were to ask the average person what a common cause of medical errors was in Canadian hospitals, chances are they might suggest lack of sleep for medical staff. After all, the conception of a resident doctor in particular, working long hours and suffering from fatigue, is engrained in the popular imagination from movies, TV shows, newspaper, and magazine articles.
It is emerging that the real picture is not so simple. Of course, not getting adequate sleep contributes to a reduced ability to concentrate at any job, however, there may be another reason for medical errors: patient handover.
Patient handover is commonly known as the critical time when updates on a patient’s condition are communicated from the doctor ending their shift to the doctor who is just starting their shift.
According to a recently-published Globe and Mail article (May 2014), the Canadian Medical Association Journal (CMAJ) reported an attempt to shorten medical staff shifts is having an unintended effect on patient care. This is because information is not always conveyed completely and, the more handovers a patient is subject to, the increased chance there is of vital information slipping through the cracks.
Medical residents in Canada work an average of 60 to 90 hours per week. In some cases, a shift can run for more than 24 hours. The exception is in Quebec, where the majority of shift lengths have been limited to 16 hours since 2011.
“I think that definitely the rest of the country should sway away from 24 hours. Issues of health and safety are universal,” Joseph Dahine, president of Fédération des Médecins Résidents du Québec, said.
Indeed, a 2010 sector report based on 23 studies pointed towards the connection between reduced shifts and improved patient safety, however, the CMAJ report, based on research by Dr. Reena Pattani during her residency at St. Michael’s Hospital in Toronto, disagrees.
“Even though it is intuitively attractive to think that if you reduce duty hours residents will be better rested and that will result in better patient care, that’s not necessarily borne out by the evidence,” Dr. Pattani said.
Through shorter shifts, the average number of handovers a patient experiences has more than doubled from three to seven, according to The Journal of the American Medical Association (JAMA).
While there are naturally scores of instances of updates being handed over effectively, the number of cases which have resulted in harm to the patient is cause for concern. In a study of interns in Canada, close to half said they had been involved in a handover which had impacted negatively on the patient.
Interns in Canada also suggested that incomplete handover was not such a rare occurrence, even if it did not lead to medical error.
Against this background, Dr. Kevin Imrie, co-chair of the Pan-Canadian Consensus on Resident Duty Hours said that Dr. Pattani’s report provided “a very balanced view”.
Fortunately, the issue is being identified and addressed. This summer a report on an improved handover process is going to be released by The Canadian Association of Interns and Residents.
Although standardizing shift lengths across Canada is not on the horizon, a more flexible schedule while training could be. Sector professionals have suggested sleep breaks during shifts and improved communication when patient handover takes could be recommended to improve patient safety.
“There’s no one-size-fits-all solution here and it’s going to depend on different training program’s needs,” Dr. Pattani said.
Pattani, Reena. “Resident Duty Hours in Canada: Past, Present and Future.” CMAJ (2014): Print.
Marshall, Lee. “Attempt to Shorten Shifts for Doctors Causing Unintended Consequences.” The Globe and Mail, 20 May 2014. Web.
Sathya, Chethan. “Shorter Shifts for Surgical Interns May Not Benefit Patients.” CBCnews. CBC/Radio Canada, 22 May 2014. Web