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住院医师取消24小时轮班制后更容易犯医疗错误
作者:小柯机器人 发布时间:2020/6/28 14:01:25

美国波士顿儿童医院Christopher P. Landrigan团队分析了住院医师取消24小时轮班制对患者安全的影响。相关论文于2020年6月25日发表于《新英格兰医学杂志》上。

取消住院医师延长工作时间对患者安全的影响尚存争议。

研究组进行了一项多中心、集群随机、交叉试验,比较了重症监护病房(ICU)儿科住院医师的两种轮班制度:延长工作时间包括轮班24小时以上的轮班表(对照轮班表),和取消延长工作时间,让住院医师在白天和晚上轮班16小时以内的轮班表(干预轮班表)。主要结局是住院医师犯下的严重医疗错误。

这两种轮班表中,ICU患者的临床特征均相似,但干预轮班组的住院医师工作量有所增加,每位医师平均负责8.8名ICU患者,显著高于对照轮班组(6.7名)。干预轮班组住院医师的医疗犯错率为每1000患者日97.1次,显著高于对照轮班组(79.0次)。干预轮班组全体严重犯错率为每1000患者日181.3次,显著高于对照轮班组(131.5次)。

但不同研究点之间差异很大。一个研究点干预轮班组的犯错率低于对照轮班组,2个研究点两组的犯错率相差不大,3个研究点干预轮班组的犯错率高于对照轮班组。在一项二次分析中,根据每位住院医师的患者数量作为潜在混杂因素进行校正,干预计划不再与错误增加相关。

总之,与研究组的假设相反,虽然分组效果因研究点而异,但取消延长工作时间轮班的住院医师比传统的延长工作时间轮班更容易犯严重医疗错误,且每位医师负责的ICU患者数量更多。

附:英文原文

Author: Christopher P. Landrigan, M.D., M.P.H.,, Shadab A. Rahman, Ph.D., M.P.H,, Jason P. Sullivan, B.S.,, Eric Vittinghoff, Ph.D.,, Laura K. Barger, Ph.D.,, Amy L. Sanderson, M.D.,, Kenneth P. Wright, Jr., Ph.D.,, Conor S. O’Brien, B.A.,, Salim Qadri, B.S.,, Melissa A. St. Hilaire, Ph.D.,, Ann C. Halbower, M.D.,, Jeffrey L. Segar, M.D.,, John K. McGuire, M.D.,, Michael V. Vitiello, Ph.D.,, Horacio O. de la Iglesia, Ph.D.,, Sue E. Poynter, M.D., M.Ed.,, Pearl L. Yu, M.D.,, Phyllis C. Zee, M.D., Ph.D.,, Steven W. Lockley, Ph.D.,, Katie L. Stone, Ph.D.,, and Charles A. Czeisler, M.D., Ph.D.

Issue&Volume: 2020-06-24

Abstract: Abstract

Background

The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial.

Methods

We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review.

Results

The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P<0.001). The number of serious errors unitwide were likewise higher during the intervention schedules (181.3 vs. 131.5 per 1000 patient-days; relative risk, 1.56; 95% CI, 1.43 to 1.71). There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors.

Conclusions

Contrary to our hypothesis, resident physicians who were randomly assigned to schedules that eliminated extended shifts made more serious errors than resident physicians assigned to schedules with extended shifts, although the effect varied by site. The number of ICU patients cared for by each resident physician was higher during schedules that eliminated extended shifts.

DOI: 10.1056/NEJMoa1900669

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1900669

 

期刊信息

The New England Journal of Medicine:《新英格兰医学杂志》,创刊于1812年。隶属于美国麻省医学协会,最新IF:70.67
官方网址:http://www.nejm.org/
投稿链接:http://www.nejm.org/page/author-center/home