The Human Factor: The Impact of Work Hours, Sleep Deprivation, and Burnout on Patient Safety Tuesday, March 20, 2007 8:00 – 9:00 p.m. EDT

Moderator:

Christopher Landrigan, MD, MPH, FAAP

Pediatric Hospitalist, Research and Fellowship Director Children’s Hospital Boston, Inpatient Pediatrics Service Boston, Massachusetts

This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

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DISCLOSURES

Activity Title: The Human Factor: The Impact of Work Hours, Sleep Deprivation, and Burnout on Patient Safety Activity Date: Safer Health Care for Kids - Webinar March 20, 2007 DISCLOSURE OF FINANCIAL RELATIONSHIPS

All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s Bureau, Stock/Bonds excluding mutual funds, Consultant, Other - identify)

CME Content Will Include Discussion/ Reference to Commercial Products/Services Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or demonstrate pharmaceuticals and/or medical devices

that are not approved No No No No Amy Fahrenkopf, MD, MPH Mark Joffe, MD, FAAP No No Yes No

DISCLOSURES

SAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMM ITTEE AND STAFF DISCLOSURE OF FINANCIAL RELATIONSHIPS

All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s Bureau, Stock/Bonds excluding mutual funds, Consultant, Other - identify)

CME Content Will Include Discussion/ Reference to Commercial Products/Services Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or demonstrate pharmaceuticals and/or

medical devices that are not approved No No No No Karen Frush, MD, FAAP (PAC Member) Uma Kotagal, MD, MBBS, MSc, FAAP (PAC Member) Christopher Landrigan, MD, MPH, FAAP (PAC Member) Marlene R. Miller, MD, MSc, FAAP (PAC Chair) Paul Sharek, MD, MPH. FAAP (PAC Member) Erin Stucky, MD, FAAP (PAC Member) Nancy Nelson (AAP Staff) Melissa Singleton, MEd (Project Manager – AAP Consultant) Junelle Speller (AAP Staff) Linda Walsh, MAB (AAP Staff) No No No No No No No No No No No No No No No No No No No No No No Not sure No No No No No No No No No No No No No

DISCLOSURES

AAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME) DISCLOSURE OF FINANCIAL RELATIONSHIPS

All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s Bureau, Stock/Bonds excluding mutual funds, Consultant, Other - identify)

CME Content Will Include Discussion/ Reference to Commercial Products/Services Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or demonstrate pharmaceuticals and/or

medical devices that are not approved Ellen Buerk, MD, FAAP No No No No No No No No Meg Fisher, MD, FAAP Robert A. Wiebe, MD, FAAP Jack Dolcourt, MD, FAAP Thomas W. Pendergrass, MD, FAAP Beverly P. Wood, MD, FAAP No No No No No No No No Not sure No No No No No No No

CME CREDIT

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAP designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

This activity is acceptable for up to 1.0 AAP credit. This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

OTHER CREDIT

This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633.

The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s) accredited by the ACCME .

TM from organizations

The Human Factor: The Impact of Work Hours, Sleep Deprivation, and Burnout on Patient Safety

American Academy of Pediatrics Webinar March 20, 2007 Christopher P. Landrigan, MD, MPH

Director, Sleep and Patient Safety Program, Brigham and Women’s Hospital Research Director, Children’s Hospital Boston Inpatient Pediatrics Service Assistant Professor of Pediatrics and Medicine, Harvard Medical School

To Err is Human

(Institute of Medicine, 1999) •

44,000 to 98,000 deaths per year

events • Focus on systemic issues due to adverse • Report notably silent on issue of provider working conditions and mental health – lack of empiric data at that time • Considerable accumulation of information in past 3-4 years

Resident Performance and Fatigue

Philibert I.

Sleep

2005; 28: 1392-1402.

-4 -3 -2 -1 0 1 2 3 4 Standard Deviations •

Effect of Sleep Deprivation on Physicians’ Mean Clinical Performance: Results of 14 Studies

• Meta-analysis 60 studies (959 MDs, 1028 non-MDs) – For MDs, 24 hours with no sleep leads to major performance drops to: • 15 th percentile of rested MD performance level • 7 th percentile tasks on

clinical

Harvard Work Hours, Health, and Safety Study

• National Study of Work Hours and Injuries in 2,737 Interns 0.2

0 0.6

0.4

0.8

1 Motor Vehicle Crashes 1.2

OR: 2.3 (95% CI, 1.6-3.3)

Crashes per 1000 commutes home

Barger LK et al. NEJM 2005; 352:125-134

0.8

1 0.2

0 0.6

0.4

1.2

1.4

Percutaneous Injuries

OR: 1.6 (95%CI, 1.5-1.8)

Injuries per 1000 opportunities

Ayas, et al. JAMA 2006; 296:1055-1062

Extended shifts Non extended shifts

Intern Sleep and Patient Safety Study

•Randomized Trial comparing interns’ alertness and performance on traditional “q3” schedule with 24-30 hour shifts (ACGME-compliant ) vs. 16 hr max schedule •

Twice as many

EEG-documented attentional failures at night on traditional schedule 0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

p=0.02

Traditional "q3" 24-30 hour shifts Intervention Schedule <16 hour scheduled shifts Attentional Failures at Night

Lockley, S. W. et al. N Engl J Med 2004;351:1829-1837

Intern Sleep and Pt Safety Study, Part 2

•Interns made 36% more serious errors on traditional schedule, including

5 times

as many serious diagnostic errors 160 140 120 100 80 60 40 20 0

p<0.001

p=0.03

Serious Medical Errors - Total Serious Medication Error

p<0.001

Serious Diagnostic Error Traditional "q3" 24-30 hour shifts Intervention Schedule - <16 hour scheduled shifts

• • •

ACGME Duty Hour Standards

<80 hours per week, averaged over four weeks <30 hours in a row, including time for hand-offs of care and education 1 day off in 7, averaged over four weeks

• Implemented in July 2003 • Goal to reduce extreme work hours, and consequently improve patient safety

ACGME Duty Hours Compliance Study

• 83.6% of interns in violation of standards during at least one month of the year • 61.5% of all inpatient intern-months in violation

Work and Sleep, Pre- vs. Post-Implementation

‡ p<0.001

‡ p<0.001

Landrigan C.P., et al. JAMA 2006;296:1063-1070

Patient Safety, Resident Sleep, Depression, and Burnout

• Mark Joffe: sleep deprivation and human performance • Amy Fahrenkopf: burnout, depression, and resident performance

Mark Joffe, MD, FAAP

Director, Community Pediatric Medicine The Children’s Hospital of Philadelphia The University of Pennsylvania School of Medicine Philadelphia, Pennsylvania

The Human Factor: The Impact of Work Hours, Sleep Deprivation, and Burnout on Patient Safety

Mark Joffe, M.D.

The Children’s Hospital of Philadelphia

“Physician, heal thyself!”

Consequences of Sleep Deprivation • Decreased longevity in animal models • Chronic hypertension • Increased cardiovascular mortality ( > 1 PPD cigarettes) • Infertility • Injuries

Social Cost of Sleep Deprivation • Depression • Divorce • Alcohol / Drug Addiction

Chernobyl 1:23 AM Bhopal 12:40 AM Three Mile Island 4:00 AM

Error Rate vs Time of Day

8A 10A 12P 2P 4P 6P 8P 10P 12A 2A 4A 6A 8A

Car Crashes vs Time of Day

1200 1000 800 600 400 200 0 8 10 12 14 16 18 20 22 0 Hour of Day 2 4 6

Federal Regulations for Truckers

10

hour maximum without break

15

hour max without 8 hour break

60

driving hours/7day period

Fatigue-Related Impairments

• Passive vigilance • Reaction time • Hand-eye coordination • Clerical accuracy • Memory • Reasoning

Provider Fatigue vs Performance

meta-analysis, resident physicians • Sleep debt < 30 hrs – Overall performance reduced 1 std deviation – Clinical Performance reduced 1.5 std deviation Philibert

Provider Fatigue vs Performance

Outcomes: attention and simulated driving • Heavy call vs light call (residents) – Reaction time 7% slower – Commission errors – Lane variability – Speed variability 40% greater 27% greater 71% greater –

Post-call performance equal to 0.05 g% blood alcohol

Arnedt

Provider Fatigue vs Alcohol

effects on performance • 18-24 hours of continuous wakefulness causes performance decline equal to blood alcohol level of 0.1% (William, Dawson)

Fatigue-related impairment expressed as “blood-alcohol equivalent”

Provider Fatigue and Medical Errors

• Medication errors 2.5 times more likely between 4-8 AM (Kozer) • Fatigued surgeons make 20% more errors in simulated laporoscopic surgery (Taffinder)

Physiology of Sleep

Circadian cycling promotes the acquisition of regular and adequate sleep



Overcoming this intrinsic biological predisposition is very, very difficult

Circadian Timekeeping

• A property of all higher life forms • Humans evolved to work during the daylight hours • “After-hours” work is a recent societal need that is out of harmony with our evolutionary inheritance

Circadian Rhythms

• Organisms have their own

endogenous

biological clock • Circadian rhythms are affected by endogenous and exogenous factors • Exogenous time setters – “Zeitgebers” light more potent than cultural/social cues

Suprachiasmatic Nucleus

• Locus of biologic rhythmicity • Neurons have circadian rhythmicity that is intracellular in origin • Genes coding for the clock function have been identified

O F

Body Temperature Cycle

99 99 98 97 97 12 16 Hour 20 MN 4 8

Measures of alertness track closely with body temperature, with nadirs is the very early morning

Mean Leg Strength

after westward flight across 5 time zones

1600 1550 1500 1450 1400 1350 1300 1250 Day 1 Day 3 Day 5 Day 7 700 1200 1700 Hour of Day 2100

Sleep Architecture

• Stage 1– if awakened people say they weren’t asleep. Automatic behavior may be Stage 1 sleep • Stage 2 – half of sleep time in stage 2 Comes between periods of deep sleep and REM

Stages 3 - 4

(Slow wave or delta sleep - SWS) Most vital, for recuperation, immune function First to be made up after sleep deprivation SWS increases after intellectually challenging tasks Most SWS occurs during the first half of the sleep period

REM

(“brain on, body off”) • Rapid eye movements • Wakeful EEG pattern • Increased cerebral blood flow • Absent spinal reflexes

Sleep Architecture

W 1 REM 2 3+4 (SWS) 1 2 3 4 5 6 7 8 75% SWS 75% REM

Slow Wave Sleep deprivation is associated with reduction in cognitive performance

REM Deprivation

• Moodiness • Hypersensitivity • Inability to consolidate complex learning

REM appears to be important for psychological well-being

Sleep Debt

• Sleep latency can be measured • Very poor correlation between self-reported sleepiness and objective measures of fatigue

Variability in Sleep Requirements

• > 7 1/2 hours is optimal for most adults • Tolerance of sleep deprivation varies • “Night owls” vs “early birds”

Light and Melatonin

• Bright light very early in the morning can cause a phase advance • Melatonin secreted by pineal gland signals brain that it is time to sleep • Light suppresses melatonin secretion

Bright lighting can reduce fatigue for workers forced to work at night

Sedative-Hypnotics • Alcohol causes sleep fragmentation and decreased REM • Most sedative-hypnotics disrupt the architecture of sleep

Age Effects

• REM and melatonin secretion decreases • Quality not maintained over 12 hour shifts • Do not tolerate irregular shifts, disrupted sleep as well as younger workers • Age correlates with increased “morningness”

At what age should overnight coverage end?

Circadian Adjustment • Circadian shift of 1-2 hours per day is maximum • Days off on regular schedule shifts cycle back towards normal

It takes at least a week and usually longer to adjust to a new shift

Short-term Countermeasures

Strategic Napping

• Schedule your sleep as you schedule your work • Avoid caffeine and alcohol before nap time • Darken the room • Make sure room is quiet or have white noise (micro-awakenings decreases time in SWS and REM)

Napping

• 23,681 Greek adults • Controlled for diet, other confounders • Mean 6.3 yr follow-up • Regular “siesta” was associated with 37% reduction in coronary mortality (Naska)

Interventions - caffeine ‘

World’s most popular drug’

• Mild CNS stimulant • 3.5 - 6 hr half-life • 250 mg improves psychomotor function if sleep deprived, 500 mg side effects w/o improvement • Tachyphylaxis • Withdrawal headaches • Affects sleep latency and sleep quality

Do you know what dose you’re taking?

• No-Doz max strength • Brewed Coffee (average) • Excedrin (2) • Instant Coffee • Mountain Dew • Orange Pekoe Tea • Coke Classic • Hershey’s Dark Chocolate • Green Tea • Hershey’s Milk Chocolate • Decaffeinated Coffee 200 mg 135 mg 130 mg 100 mg 55 mg 50 mg 35 mg 30 mg 30 mg 10 mg 5 mg

Modafinil “

Provigil”

• Narcolepsy • Obstructive Sleep Apnea • Military “short-term fatigue countermeasure” • Shift Work Sleep Disorder

The only way to completely reverse the physiologic need for sleep is to sleep

Summary

• The evidence that fatigue impairs human performance is incontrovertible • Physicians are human • Fatigue is a root cause of many medical errors

Summary Optimizing performance requires that sleep management be high-priority!

– Schedule clinical work with sleep in mind – Just say no to meetings and other commitments that disrupt optimal sleep management (and expect it from colleagues) – Family life must accommodate to sleep needs for physicians with after-hours responsibilities

References

1. Naska A, Oikonomou E, Trichopoulou A. Siesta in healthy adults and coronary mortality in the general population.

Arch Intern Med

167:296, 2007.

2. William AM, Feyer A. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication.

Occ Environ Med

57(10):649-655, 2000.

3. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination.

Sleep

28(11):1392, 2005.

4. Arnedt JT, Owens J, et al. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.

JAMA

294(9):1025, 2005.

5. Dawson D, Reid K. Fatigue, alcohol and performance impairment.

Nature

388(6639):235, 1997.

6. Taffinder NJ, McManus IC, Gul Y, et al. Effect of sleep deprivation on surgeons’ dexterity on laparoscopy simulator.

Lancet

1191:352, 1998. 7. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients.

NEJM

324(6):377-384, 1991.

8. Institute of Medicine,

To Err is Human

, National Academy Press 2000, Washington, D.C., p 49.

9. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients.

JAMA

285:2114-2120, 2001.

10. Kozer E, Scolnik D, Macpherson A, et al. Variables associated with medication errors in pediatric emergency medicine.

Pediatrics

110(4):737-742, 2002.

References

11. Dement WC.

The Promise of Sleep,

Delacorte Press, NY 1999, p262-263.

12. Akerstedt T, Knutsson a, AlfredssonL, et al. Shift work and cardiovascular disease.

Scand J Work Environ Health

10:490, 1984

.

13. Earnest DJ, Liang F, Ratcliff M, et al. Immortal time: Circadian clock properties of rat suprachiasmatic cell lines.

Science

283(5404):693, 1999.

14.

Van Dongen HP . Baynard MD . Maislin G . Dinges DF . Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Sleep. 27(3):423-33, 2004.

15.

Van Dongen HP . Vitellaro KM . Dinges DF . Individual differences in adult human sleep and wakefulness: Leitmotif for a research agenda.

Sleep

28(4):479-96, 2005.

16. Weitman ED, Moline ML, et al. Chronobiology of aging: Temperature, sleep wake rhythms and entrainment.

Neurobiol Aging

3:299-309, 1982.

17. Reid K, Dawson D. Comparing performance on a simulated 12 hour shift rotation in young and older subjects.

Occ Environ Med

58(1):58-62, 2001.

18.

Landrigan CP, Rothschild JM, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units.

NEJM

351(18):1838, 2004.

19.

van Duinen H , Lorist MM , Zijdewind I . The effect of caffeine on cognitive task performance and motor fatigue.

Psychopharmacology.

180(3):539-47, 2005.

20. Czeisler CA, Walsh JK, Roth T, et al. Modafinil for excessive sleepiness associated with shift-work sleep disorder.

NEJM

353(5):476, 2005.

Amy Fahrenkopf, MD, MPH

Pediatric Hospitalist Children’s Hospital Boston Boston, Massachusetts

Effects of Housestaff Burnout and Depression on Patient Safety American Academy of Pediatrics Webinar March 20, 2007 Amy M. Fahrenkopf, M.D., M.P.H.

Department of Medicine Children’s Hospital Boston

Introduction

• Depression and burnout are highly prevalent among medical residents • Studies have documented burnout rates of 41-76%, while depression rates have ranged from 7-56% • Despite their frequency, little research has sought to quantify the effects of depression and burnout on patient care.

Burnout: Definition

• Burnout is a syndrome of emotional depletion and detachment that develops in response to chronic occupational stress • Burnout more likely to develop when job stress is high and personal autonomy is low • Differs from depression in that it primarily affects functioning within the work context, not other areas of an individual’s life

Burnout: Screening

• Maslach Burnout Inventory – Gold standard for evaluating burnout – 22 question validated screening tool – Version available that is specific to health care industry – Identifies three domains of burnout: • Emotional exhaustion • Depersonalization • Low personal achievement

Burnout in Residency: What do we know?

• Growing area of research, though studies tend to be small and single-centered • Burnout is a significant problem in all specialties – Medicine: 41-76% – OB/Gyn: 50% – Pediatrics: 76% – Anesthesia: 47% – Surgery: 50-56%

Burnout in Residency: What do we know?

• Burnout levels rise quickly within the first few months of residency • Burnout affects residents of all PGY levels equally, although depersonalization scores rise with each additional year of residency • Men may be affected more than women • ACGME work hour changes appear to have decreased burnout rates moderately, but study results have been contradictory

Depression: Definition and Screening

• Depressed mood and loss of interests for at least two consecutive weeks that interferes with daily life and normal functioning • In any given 1-year period, 9.5% of the general population will suffer from a depressive episode • Clinical diagnosis with many excellent, validated screening tools available

Depression in Residency: What do we know?

• Considerably less research done on resident depression than on burnout • Studies report prevalence rates from 7-56% • Studies to date focus solely on intern year • Multiple studies have shown residents start intern year with low rates of depression (2 4%) and jump to 30-56% within 3 to 6 months

Depression in Residency: What do we know?

• Most depressed residents are also burned out (80-95%) • Most residents who screen positive for depression in these studies have no prior history of depression • Female residents more likely to be depressed

Depression and Burnout: Is there a link to medical errors?

• All published studies to date have focused on burnout and the link to self reported medical errors or quality of care • No published study has attempted to link depression to medical errors • We will look at three studies that highlight the important issues

Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program

Shanafelt TD, Bradley KA, Wipf JE, Back AL;

Ann Intern Med.

2002; 136:358-367 • Survey of 115 internal medicine residents at University of Washington • Burnout measured by MBI • Self-reported patient care determined using tool developed for this study • Depression measured using two question PRIME-MD screen

Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program

Shanafelt TD, Bradley KA, Wipf JE, Back AL;

Ann Intern Med.

2002; 136:358-367 • 76% burnout rate, of whom 50% also screened positive for depression • Burned out residents significantly more likely than non-burned out residents to report one or more suboptimal patient care monthly (53% vs 21%; p=0.004) • In multivariate analyses burnout (but not sex or depression) associated with self-report of suboptimal patient care monthly (odds ratio 8.3 [95% CI, 2.6-26.5])

Association of Perceived Medical Errors with Resident Distress and Empathy

West CP, Huschka MM, Novotny PJ, et. al.

JAMA

. 2006; 296:1071-1078 • Prospective longitudinal cohort study of 184 internal medicine residents at Mayo Clinic • Residents completed surveys of their quality of life and self-reported medical errors every three months for one year • Quality of life survey included MBI, 2-question depression screen, and a validated quality of life scale

Association of Perceived Medical Errors with Resident Distress and Empathy

West CP, Huschka MM, Novotny PJ, et. al.

JAMA

. 2006; 296:1071-1078 • 34% of residents reported making at least one major medical error • Self-perceived errors were associated with increased burnout in all domains (DP +3.23, p<0.001; EE+6.85, p<0.001; PA –2.99, p=0.001)

Association of Perceived Medical Errors with Resident Distress and Empathy

West CP, Huschka MM, Novotny PJ, et. al.

JAMA

. 2006; 296:1071-1078 • Self-perceived errors associated with odds ratio of 3.29 (95%CI, 1.90-5.64) of screening positive for depression at next survey point • Increased burnout scores, in turn, associated with increased odds of self reported errors in following 3 months

Rates of Medication Errors Among Depressed and Burned Out House Officers

Fahrenkopf AM, Sectish TC, Barger LK, et.al (

Presented at )

• Prospective cohort study of 123 pediatrics residents at 3 large Children’s Hospitals: – Children’s Hospital Boston – Lucile Packard Children’s Hospital – Children’s National Medical Center • Involved 3 components: – Baseline resident questionnaire with MBI and 10 question HANDS depression screen – 6 week resident sleep and work hour logs – Medication error collection at two sites

Housestaff Burnout and Depression: The Link to Patient Safety

Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation, Agency for Healthcare Research and Quality Patient Safety Conference, Washington D.C., 2006 • 19.5% of residents depressed and 74% burned out • 96% of depressed residents also burned out • 74% of those depressed had no prior history of depression • No correlation between depression or burnout with PGY year, gender, marital status, or self reported sleep or work hours

Housestaff Burnout and Depression: The Link to Patient Safety

Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation, Agency for Healthcare Research and Quality Patient Safety Conference, Washington D.C., 2006 • 10,277 orders reviewed with 125 errors identified • 45 errors made by study subjects – 0 preventable adverse drug events, 28 potential adverse events, and 17 errors with little potential for harm.

– 1 non-preventable ADE

1

Housestaff Burnout and Depression: The Link to Patient Safety

Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation, Agency for Healthcare Research and Quality Patient Safety Conference, Washington D.C., 2006 4 3 2 1 0 2 3 depressed not depressed ‡p<0.05 ‡‡ p<0.01 ‡‡‡p<0.001 burned out not burned out

Housestaff Burnout and Depression: The Link to Patient Safety

Fahrenkopf AM, Sectish TC, Barger LK, et.al. Platform presentation, Agency for Healthcare Research and Quality Patient Safety Conference, Washington D.C., 2006

Depression, Burnout, and Self-reported Medical Errors

Has made "significant" medical error due to sleep deprivation Has made "significant" medical error due to any cause ‡ ‡ 0 10 20 30 40 50 60 70 80 90 100 Not burned out Burned out Not depressed Depressed ‡p<0.05 ‡‡ p<0.01 ‡‡‡p<0.001

Areas for Further Research

• Investigate the causal relationship between depression and errors • Better define how depression and burnout affect residents and patient care in other specialties AND among fellows and practicing physicians • Rigorously conducted intervention trials are needed to evaluate how to improve the mental health of trainees while decreasing medical errors and preserving educational quality.

Conclusion

• Depression and burnout are significant problems among pediatric residents in all years of training • Both depressed and burned out residents self-report high rates of errors and poor health • Preliminary studies suggest that depressed residents have a nearly eight-fold increase in errors compared to their non-depressed colleagues

Conclusion

• ACGME work hour regulations may have decreased burnout, but no change in depression • Further studies are needed to better establish the relationship between depression, burnout, and medical errors

Acknowledgements

Pediatric Work Hours Study Group Harvard Work Hours, Health and Safety Group Christopher Landrigan, MD, MPH