A study published online on June 4, 2018 in JAMA Internal Medicine concluded, “Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.”
The study sought to investigate the question, “What is the effect of increased attending physician supervision on a resident inpatient team for both patient safety and educational outcomes?”
The investigators conducted a 9-month randomized, cross-over trial on an inpatient medicine teaching service where 22 faculty provided either: 1) direct supervision where attendings joined work rounds on established (previously admitted) patients or 2) standard supervision where attendings were available, but did not join work rounds. Each faculty member participated in both arms in random order.
The primary safety outcome was rate of medical errors. Secondary safety outcomes included deaths and transfers to the intensive care unit. Resident education was evaluated via a time motion study to assess resident participation on rounds and surveys to measure resident and attending educational ratings.
The study’s attending physician participants were 22 teaching attendings on the medicine service at Massachusetts General Hospital, and the resident physicians were on the medical service at Massachusetts General Hospital. Eight of the attending physicians were women, with fifteen of the attending physicians having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis.
Five research nurses reviewed the medical records, formal incident reports from the hospital incident-reporting system, daily pharmacy reports, pharmacy paging logs and solicited reports from nurses working on the study units and noted any adverse events or near misses. Four physician investigators, blinded to attending and intervention, classified each suspected incident as an adverse event, near miss or exclusion (an incident determined to be neither a medical error or adverse event). Physician reviewers further classified all adverse events as preventable or non-preventable.
The investigators used a 20 question survey asking about resident and faculty experience with different levels of faculty supervision. The survey questions each were followed by a 5 point scale with a range from strongly agree, agree, neutral, disagree to strongly disagree. Strongly agree represents a better outcome. There were no subscales.
The study found that the medical error rate was not significantly different between standard vs increased supervision.
The study found that interns spoke less when an attending physician joined rounds and reported feeling less efficient and less autonomous with an attending physician present. Residents felt less autonomous. Attending physicians rated the quality of care higher when they participated on work rounds.
The study started in September 2015, the study’s primary completion dated was June 2016, and the study’s actual completion date was April 2017.
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