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Additional questions are whether all patients were cared for by a trainee or whether attending physicians were distracted by the act of orienting the trainees during their first few weeks. I hate for policy changes to be enacted related to an inaccurate assessment of causality. Loree Sent from my HTC smartphone ________________________________ From: Ash Paul <[log in to unmask]> Sent: Saturday, July 24, 2010 4:26 AM To: [log in to unmask] <[log in to unmask]> Subject: Re: JGIM article: Spike in Medication Errors in July Dear Bill and Rakesh, There is a reletively similar study about the NHS: Early In-Hospital Mortality following Trainee Doctors' First Day at Work You can read the article at following PLOS weblink: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0007103 However, the NHS Knowledge Service, while critically appraising the article, had this to comment: This is a large, generally well-conducted retrospective cohort study. It noted a small but significant difference in mortality for emergency hospital admissions on the first Wednesday in August compared with the last Wednesday in July. This observation, referred to in the US as the 'July phenomenon', has been investigated in several studies with inconsistent findings. In this study, the researchers attempted to avoid the possible biases that the other studies investigating this July phenomenon may have faced. For example: * They only included emergency admissions to address the possible bias that elective admissions may be planned around the holiday period and upcoming change in hospital staff. * They followed patients for a short period (one week) because later deaths may not reflect the quality of initial management and care. * They used routinely collected data for a large number of patients. There are some points to bear in mind when considering the findings of this study: * The absolute number of increased deaths in the August admissions was small, that is, a total of 45 in nine years (2,227 compared with 2,182). This is 45 deaths too many, particularly if there is a link to the quality of care these patients received, but the 6% increased odds must be interpreted alongside the actual numbers who died. * The research highlighted a consistent pattern across the years: that admissions on the first Wednesday in August were consistently fewer than the number of admissions on the last Wednesday in July. This pattern suggests some systematic differences in referrals that needs further investigation. For example, patients with less severe illness, and who have the choice, may prefer to be admitted in July before the staff handover. As such, unmeasured factors in relation to who is admitted and why they are admitted may play a part. * With data on almost 300,000 admissions, the results are statistically significant but only just. From these results, it isn’t possible to conclude that poorer care is responsible for the higher deaths in the first week in August. Further study of individual cases and a quantification of the number of preventable deaths would be helpful and the researchers specifically call for this. Hope you find this useful. Regards, Ash Dr Ash Paul Medical Director NHS Bedfordshire 21 Kimbolton Road Bedford MK40 2AW Tel no: 01234897224 Email: [log in to unmask]<mailto:[log in to unmask]> ________________________________ From: "Bill Cayley, Jr" <[log in to unmask]> To: [log in to unmask] Sent: Sat, 24 July, 2010 5:04:06 Subject: Re: JGIM article: Spike in Medication Errors in July At least from the abstract, the stats sounds like they were done in a reasonable way with resonable comparisons. This specific issue has not come up for us, but we as faculty do provide closer supervision of our new residents both in hospital and in clinic during the first few months. I think the really interesting next question would be if there was a difference between community-based hospitals with residents, and university-based hospitals. A bit more challening to sort out statistically, i imagine. Thanks for passing on BC Bill Cayley, Jr, MD MDiv<http://www.fammed.wisc.edu/directory?firstname=&lastname=cayley> [log in to unmask]<mailto:[log in to unmask]> Work: Augusta Family Medicine 207 W Lincoln, Augusta, WI 54722<http://maps.yahoo.com/maps_result?q1=207+W+Lincoln%2C+Augusta%2C+WI+54722+> Tel: 715-286-2270 Pager: 715-838-7940 Home: 3604 Sharon Drive, Eau Claire, WI 54701 Tel: 715-830-0932 Mobile: 715-828-4636 A cheerful heart is good medicine... (Proverbs 17:22) --- On Fri, 7/23/10, Rakesh Biswas <[log in to unmask]> wrote: From: Rakesh Biswas <[log in to unmask]> Subject: JGIM article: Spike in Medication Errors in July To: [log in to unmask] Date: Friday, July 23, 2010, 10:49 PM Would be nice to know what this group thinks of this article. regards, rakesh ---------- Forwarded message ---------- From: Shannon Mills <[log in to unmask]<http:[log in to unmask]>> Date: Sat, Jul 24, 2010 at 1:36 AM Subject: Spike in Medication Errors in July To: [log in to unmask]<http:[log in to unmask]> Dear colleagues, An interesting article titled “A spike in fatal medication errors: a possible effect of new medical residents” was published in the Journal of General Internal Medicine last month. The abstract is included below. • What’s your reaction to the article? • Has this come up in conversation on your campus or at your organization? • How can you, your residents, or IHI Open School Chapters respond? > Click here to read the full article<http://www.springerlink.com/content/n502614282p9266t/fulltext.html>. J Gen Intern Med.<http://www3.interscience.wiley.com/journal/118582542/home> 2010 Aug;25(8):774-9. Epub 2010 May 29. A july spike in fatal medication errors: a possible effect of new medical residents. Phillips DP<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Phillips%20DP%22%5BAuthor%5D>, Barker GE<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Barker%20GE%22%5BAuthor%5D>. Comment in: J Gen Intern Med. 2010 Aug;25(8):760-1. <http://www.ncbi.nlm.nih.gov/pubmed/20532649> Abstract BACKGROUND: Each July thousands begin medical residencies and acquire increased responsibility for patient care. Many have suggested that these new medical residents may produce errors and worsen patient outcomes-the so-called "July Effect;" however, we have found no U.S. evidence documenting this effect. OBJECTIVE: Determine whether fatal medication errors spike in July. DESIGN: We examined all U.S. death certificates, 1979-2006 (n = 62,338,584), focusing on medication errors (n = 244,388). We compared the observed number of deaths in July with the number expected, determined by least-squares regression techniques. We compared the July Effect inside versus outside medical institutions. We also compared the July Effect in counties with versus without teaching hospitals. OUTCOME MEASURE: JR = Observed number of July deaths / Expected number of July deaths. RESULTS: Inside medical institutions, in counties containing teaching hospitals, fatal medication errors spiked by 10% in July and in no other month [JR = 1.10 (1.06-1.14)]. In contrast, there was no July spike in counties without teaching hospitals. The greater the concentration of teaching hospitals in a region, the greater the July spike (r = .80; P = .005). These findings held only for medication errors, not for other causes of death. CONCLUSIONS: We found a significant July spike in fatal medication errors inside medical institutions. After assessing competing explanations, we concluded that the July mortality spike results at least partly from changes associated with the arrival of new medical residents. ________________________________ This e-mail and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to whom they are addressed. 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