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The July Weekend Effect


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The July Weekend Effect

By Jock Hoffman, CRICO

Related to: Cures Act: Opening Notes, Emergency Medicine, Primary Care, Obstetrics, Other Specialties, Surgery, Teamwork Training

Is health care safer at 10:00 a.m. on a Tuesday in May than it is on a Saturday night in July? Is the “weekend effect” or the “July effect” a myth of conventional wisdom or a fact substantiated by randomized controlled trials? And, if patients are indeed at greater risk on weekends in July, what’s to be done about it?

A cross section of studies suggests the theories of outcome variation by day or month may be more than anecdotal:

Surgical outcomes: a progressive reduction in mortality over the course of the academic year

Cardiac outcomes: worse patient outcomes from in-hospital cardiac arrests on the weekend

Stroke: 10.1 percent of stroke patients died when admitted on the weekend versus 7.9 percent on weekdays

Documentation: the average charting error rate for July (23.6%) was significantly higher than in June (16.8%)

Emergency Medicine: trauma patients treated at the beginning of the academic year had a significantly higher rate of preventable and potentially preventable complications when compared with the patients treated for their injuries in May or June.

Overall: for teaching hospitals, the average mortality increases by four percent in July; nationally, this translates to 1,500-2,750 deaths per year.

Theories abound as to the factors behind the weekend phenomena including: lower staff-to-patient ratios, less experienced staff working less desirable shifts, reduced access to specialists and services, and even the prescribed weekend peacefulness that may inhibit an appropriate escalation of treatment.

As for the risks associated with an annual influx of inexperienced caregivers, that might not be the only factor making July and August less safe for patients. The vacation schedules of supervising clinicians may be leaving an already vulnerable house staff even more exposed.

Less well studied is whether there is any link between these temporal phenomena and medical error or negligence. Specifically dating a precipitating adverse event can be a challenge, especially if it comprises multiple errors across a lengthy course of care. Nevertheless, every case in the CRICO malpractice database is assigned a loss date. Each case is also coded for the severity of the patient’s injury. The proportion of high severity cases (i.e., a significant injury or death) are shown below by day of the week and by month.

Ascertaining whether or not the claims data validate or dispel these effects requires deeper analysis than this broad overview, but health care providers may want to investigate their local data to determine if a subset of patients are at increased risk. In addition to reviewing error-related data to look for potential weaknesses, patient safety leaders might consider weekend walk rounds and self assessments.


High-severity injury cases by day of week



High-severity injury cases by month



February 1, 2010
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