Errors by hospital residents often down to poor teamwork, communication

Physicians-in-training are highly vulnerable to making medical errors that stem from teamwork breakdowns, especially a lack of supervision by experienced staff, according to a new study funded by HHS' Agency for Healthcare Research and Quality.

Teamwork breakdowns involving medical residents, fellows and interns (first-year residents) also caused a significant number of errors to occur during patient handoffs, researchers found. The study, “Medical Errors Involving Trainees: A Study of Closed Malpractice Claims from 5 Insurers,” appears in the October 22, 2007, issue of the Archives of Internal Medicine .

Researchers at the Michael E. DeBakey Veterans Affairs Medical Center, the Baylor College of Medicine, the University of Texas Medical School at Houston, and the Harvard School of Public Health analyzed data from a random sample of 889 closed malpractice claims which had been reviewed by specialist physicians between 2002 and 2004. The reviewers had determined whether injuries had occurred, and, if so, whether they were due to errors involving medical trainees. The study focused on four clinical categories: obstetrics, surgical, missed and delayed diagnoses, and medications. Collectively, these four categories cover approximately 80 percent of all U.S. medical malpractice claims.

Of the closed medical claims involving both error and injury, more than one-fourth (27 percent), or 240 cases, involved trainees whose role in the error was considered to be at least moderately important, the study found. Medical residents were involved in 87 percent of those cases; interns and fellows each were participants in 13 percent. Adverse outcomes were serious: one-third resulted in significant physical injury, one-fifth in major physical injury, and one-third resulted in death. Nearly a third of the cases took place in the outpatient setting.

“We are continuing to learn about the critical role that effective teamwork plays in preventing medical errors and promoting patient safety,” said AHRQ Director Carolyn M. Clancy, MD. “This study reminds us that we have a lot to do to ensure that hospitals are providing appropriate supervision to trainees and implementing team-training programs, both in the inpatient and outpatient setting.”

Researchers also examined the role of trainee errors attributable to cognitive factors, such as judgment and technical knowledge shortcomings, and to teamwork factors, including supervision and patient handoffs. Cognitive factors contributed to the majority of trainee errors, according to the study. Nearly three-fourths (72 percent) involved errors in judgment, more than half (58 percent) were caused by a lack of technical knowledge, and more than half (57 percent) were due to failure of vigilance or memory. Teamwork factors, notably lack of supervision and handoff problems, were also a significant issue, accounting for 70 percent of the cases involving trainee errors. A lack of supervision accounted for more than half (54 percent) of the trainee errors, and handoff problems accounted for nearly one-fifth (19 percent). Because multiple factors contributed to trainee errors, the percentages do not add up to 100 percent.

Attending physicians' failure to oversee the work of trainees was identified as a factor in 82 percent of the 129 cases where a lack of supervision contributed to a medical error, the study found. Supervision failures by both the senior resident and attending physician also played a contributing role.

Errors stemming from handoff problems were due to a variety of communication breakdowns, researchers found. In 34 percent of the cases where a handoff error occurred, an incomplete or inaccurate transfer of information took place between two trainees. However, handoffs problems occurred almost as frequently between trainees and attending physicians, with a transfer of information that resulted in an error taking place in 32 percent of cases.

Chains of communication in which information breakdowns occurred were complex, the study noted. In a fifth of the cases, more than two entities were involved; in nearly a quarter, interactions with nurses, pharmacy and laboratory personnel were involved.

Despite a growing body of evidence that links poor teamwork and preventable medical errors, graduate medical education programs continue to pay insufficient attention to teamwork-based training and communication skills, according to study authors. Telephone communications were “problematic” in several cases, they said, but proficiency in this area has still received scant attention. In addition, specific instructional strategies to improve technical skills, such as use of simulation and information technology, deserve closer attention.

“Our study confirms the relationship of poor teamwork to preventable errors and quality of care,” said study lead author Hardeep Singh, MD, MPH. Given the increasing pressure to identify and address causes of medical errors, the study findings “should help leaders of residency programs and the [Accreditation Council for Graduate Medical Education] to orient training interventions toward these problem areas,” he said.