Errors by Resident Physicians Often Result of Inadequate Supervision

HOUSTON, Oct. 25 -- Medical errors by resident physicians in U.S. hospitals stem from lack of judgment and technical competence but also from inadequate supervision by senior physicians, a study of malpractice claims found.
Among 240 claims in which trainees (mainly residents) were judged to have played an important role, errors of judgment was the most frequent contributing factor, found in 72% of cases, Hardeep Singh, M.D., M.P.H., of Baylor College of Medicine here, and colleagues, reported in the Oct. 22 issue of Archives of Internal Medicine.
Breakdowns in teamwork was a close second at 70% and lack of technical competence was found in 58% of cases, the researchers said.
Trainees are inexperienced, often tired, and occasionally unsupervised, and they tend to work at medical centers treating the sickest patients, the researchers noted. Yet there has been limited information about the types and causes of trainees' errors.
To remedy this, they studied closed claims from five malpractice insurance companies in four regions of the U.S.
The claims were closed between 1984 and 2004, and the errors occurred between 1979 and 2001.
Specialist physicians reviewed a random sample of the claims and determined whether injuries had occurred, and if so, whether they were caused by a medical error.
Of 889 cases (claims with both error and injury) identified, 240 (27%) involved trainees whose role was judged to be at least moderately important.
Nearly 80% of the cases involved trainee physicians in obstetrics-gynecology, general surgery, adult primary care, orthopedic surgery, and pediatrics. Three out of 10 were in obstetrics-gynecology.
The researchers also compared the characteristics of cases in which trainees were involved with cases that did not involve trainees and probed trainee errors attributed to teamwork problems and lack of technical competence or knowledge.
Among the 240 cases, there were 173 that exhibited errors in judgment (72%), 167 that showed teamwork breakdowns (70%), and 139 in which lack of technical competence played a role (58%).
As examples of lack of technical competence, the investigators noted a case in which a surgical resident missed the diagnosis of a bile leak after abdominal surgery and another in which an obstetric resident misdiagnosed a breech presentation.
Lack of supervision and hand-off problems were the most common types of teamwork snafus, and both were disproportionately more common among errors that involved trainees than among those that did not (respectively, 54% versus 7% and 20% versus 12%).
In 82% of the cases involving lack of supervision, the failure lay with attending physicians. In 12% of the cases, both senior residents and attending physicians failed to provide residents with proper supervision, the researchers said.
The most common task during which failure of technical competence occurred were diagnostic decision-making and monitoring the patient or situation. Trainee errors appeared
more complex than nontrainee errors (mean of 3.8 contributing factors versus 2.5 [P<0.001]).
Secondary tasks, such as monitoring, were also associated with cases of technical competence problems. For example, one resident's failure to diagnose a high-risk pregnancy was accompanied by inadequate fetal monitoring.
Not only were hand-off problems a factor, but so were poor teamwork and transfer problems between trainees and attending physicians, nurses, pharmacists, and laboratories.
The methodological approach in this study had a number of advantages over those previously used, the researchers said. However, there were limitations, they noted, including the fact that litigated claims are just the "tip of the iceberg" of all errors.
Also, certain contributing factors may not have been detectable through claims reviews. Thus, fatigue and workload were particularly likely to have been undocumented, unless they were part of the plaintiff's allegation.
Finally, the reviewers' judgments of the appropriateness of care may have been biased by the knowledge of the litigation outcome, they said.
The characteristics detected in malpractice claims data suggest special vulnerabilities around teamwork, levels of supervision, and diagnostic decision-making, the investigators said.
Their findings should help leaders of residency programs and the Accreditation Council for Graduate Medical Education orient training interventions toward these problem areas and also stimulate further research into why and how trainee errors occur, they concluded.
In an accompanying editorial, Robert A. Phillips, M.D., Ph.D., of UMass Memorial Medical Center in Worcester, and Julia D. Andrieni, M.D., proposed a new collaborative, payer-driven model for inpatient care. That model would include:
Medical care teams consisting of house officers, hospitalists, and nursing staff, with hospitalists as the central glue.
Coordinated work hours and shifts, so that patients have the greatest chance of being cared for by the same team.
Coordinated work and discharge rounds.
Monitoring outcomes with measures from the Joint Commission on Accreditation of Healthcare Organizations and developing new patient safety measures.
Payer reimbursement tied to this new structure of medical teams and documentation. Hospitals that attain this goal should receive a higher compensation rate from payers.
The Centers for Medicare and Medicaid Services, insurance companies, and federally funded graduate medical education would probably support such a model, Dr. Phillips and Dr. Andrieni said. Initially, however, hospital administrators, program directors, hospitalists, and nurses might view this as too onerous, they noted.
In the end, they wrote, to address the issues raised by this study, "We really do not have a choice but to implement a new model of coordinated care."