Work hour rules and contributors to patient care mistakes: A focus group study with internal medicine residents

BACKGROUND: The “Swiss cheese model” of systems accidents is commonly applied to patient safety, implying that many “holes” must align before an adverse event occurs. The Accreditation Council for Graduate Medical Education (ACGME) instituted work hour limitations to fill one such hole by reducing resident fatigue. OBJECTIVE: The objective of this study was to determine how residents perceive the impact of the ACGME rules and other factors on patient safety. DESIGN: The study was designed as a focus group study. PARTICIPANTS: Participating in the study were 28 internal medicine residents, of whom 13 were from a university‐based program that includes both an academic medical center and a Veterans Affair (VA) hospital, 9 were from a community‐based program, and 6 were from a freestanding medical college that includes a large private teaching hospital and a VA hospital. MEASUREMENT: Grounded theory analysis was used to examine transcripts of the focus group discussions. RESULTS: A model of contributors to patient care errors emerged including fatigue, inexperience, sign‐outs, not knowing patients, “entropy” (which we defined as “overall chaos in the system”), and workload. Participants described the impact of both intended and unintended consequences of the work hour rules on patient care. Residents reported improved well‐being and less fatigue, but had concern about the effect of reduced continuity on patient care. CONCLUSION: Our focus group participants perceived that the ACGME work hour limitations had minimized the impact of resident fatigue on patient care errors. Other contributors to errors remained and were often exacerbated by methods to maintain compliance with the rules. Journal of Hospital Medicine 2008;3:228–237.