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The Nature of Resident Errors

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The Nature of Resident Errors

By Tom A. Augello, CRICO

Related to: Clinical Guidelines, Communication, Diagnosis, Emergency Medicine, Primary Care, Obstetrics, Other Specialties, Surgery, Teamwork Training

Research points to flawed hand-offs, judgment, and supervision.

Guest Commentators

 

  • Sheila R. Barnett, MD; Beth Israel Deaconess Medical Center; Boston, MA
  • Aaron S. Kesselheim, MD, JD; Brigham and Women’s Hospital; Boston, MA
  • Hardeep Singh, MD, MPH.; Baylor College of Medicine; Houston, TX

Transcript

In medical malpractice lawsuits that name physician trainees as defendants, the most common contributing factors are errors in judgment, teamwork failures, and lack of technical competence … in that order. Among the teamwork failures, a lack of supervision and hand-offs are most prevalent.

Those findings were part of a study of medical errors that looked at thousands of malpractice cases from five liability insurers across the United States. The report on trainee involvement in errors was published late in 2007 in the Archives of Internal Medicine by Singh and colleagues. The findings have liability and quality-of-care implications not only for trainees, but also for the physicians who supervise them.

“The goals were to give a descriptive analysis of the types of errors that trainees made, and there has been very little in the literature about this.”

Dr. Hardeep Singh was lead author of the study. Dr. Singh is an Assistant Professor at Houston VA Hospital in Texas. CRICO/RMF, the malpractice and patient safety company owned by the Harvard medical system, was a co-sponsor.

Contributing factors for trainee errors were divided into two categories: cognitive factors and system factors. When examining the cognitive errors that residents, fellows and interns make, a lack of technical competence or knowledge was present in 58 percent of the cases, but errors in judgment were more common, showing up in 72 percent of the cases.

“It is not just the knowledge but the application of knowledge and the clinical reasoning which you use to make decisions for patients, which is sort of more important than just knowledge itself. It just goes to show you that most physicians have the knowledge, but in the application of the knowledge, whether it be due to some cognitive factors or individual factors, or some system-related factors, it is the judgment which is really key for such errors.”

The most common tasks associated with trainee errors were diagnostic decision-making and monitoring activities. Dr. Singh says that even in the area of technical competence, the problems identified in his study suggest that attention should not be limited to procedural issues.

“We had cases where they did the surgery just fine, but for instance, they missed the diagnosis of a compartment syndrome two days post surgery. So the task was not really a procedural task. It was actually diagnostic decision making. For surgical patient safety, you just can’t emphasize procedures and technical competence in terms of getting stitches right and things like that. That’s important, but things like making a diagnosis as it relates to their field, which is postoperative, sometimes preoperative, it’s really important. That’s one of the things we found a little surprising that even in other fields like surgery and OB, not just medicine where we think most of the diagnosis is made.”

The role of supervision and handoffs in the errors involving trainees also came through in the malpractice data when looking at system factors, rather than cognitive factors. Lack of supervision was identified in 54 percent of the cases, while hand-off errors were present in 19 percent.

Dr. Sheila Barnett is the Director of Graduate Medical Education at Beth Israel Deaconess Medical Center in Boston. Dr. Barnet thinks the findings in the Singh study can help residency programs provide focus for supervision.

“We have restricted the number of hours residents spend with patients now. Judgment is often based on your experience and your exposure. Have you seen that case before? What happened the last time? I believe a lot of that knowledge is experience. How many cases did you see? If you have seen five, you’re more expert that if you have seen one. If you have seen 100, you know, that’s what makes the senior attending so valuable is that they have seen different diseases present every way they can. I think the judgment and the supervision, what that reflects is that perhaps these residents haven’t seen enough patients and they aren’t ready to be able to make the call.”

Dr. Barnett says that supervision issues are only more pronounced today with recent limits on resident duty hours. The result is that attending presence in the hospitals is greater, accompanied by more attention on the quality of supervision.

“Certainly here we now have, you know, every program has a supervision policy that 15 years ago we didn’t have. We ask attendings in programs about the supervision. When we internally review the ACGME programs, we ask the residents specifically, what is the chain of command? Who do you call? Is somebody always available? Unfortunately, a lot of the time that gets at the emergencies and the crises, and we have done well there. Some of the harder part of supervision is when it’s not a crisis and where is the attending, when do you call, that type of what I consider judgment-type calls.”

Improving supervision involves both sides of that relationship—resident, and attending physicians. Dr. Aaron Kesselheim is a physician and an attorney, and an Instructor in Medicine at Harvard Medical School. Dr. Kesselheim sees patients in a primary care clinic at Brigham and Women’s Hospital in Boston and he supervises residents. He is currently developing a web-based CME course in supervision.

“The role of the attending and the type of communication that attendings have with their residents are very individualized and personality dependent. There are ways to try to focus on important aspects of that communication that can be made a part of each attending resident interaction. For example, there are ways to systematize both what residents should expect from their attendings when the attendings want to hear about patients or what sort of information the resident should be presenting to them. There are ways to systematize, as I said, these trigger points that should trigger a resident communicating with their supervising physician so that the supervision physician is aware of the situation and can contribute their experience and their knowledge to help resolve a patient who is doing worse.”

 

These protocols might help improve the kinds of problems with hand-offs identified in the Singh study. Prior studies have identified increased risks associated with increased transfers of patient information with duty hour limits, but the Singh study goes further. It showed that hand-off problems with trainees are as likely to involve attendings as other residents.

As for the implications for malpractice litigation, Dr. Kesselheim notes that residents are sued and held to the standards of any physician practicing in their specialty performing similar procedures. Attendings are not liable for their resident’s negligence; however, supervisors can be brought into the case and are liable if the supervision itself is proven to be sub-par.

 


March 1, 2008
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