AHRQ: IOM Recommends Residents Get More Sleep, Supervision to Improve Patient Safety


March / April 2009

IOM Recommends Residents Get More Sleep, Supervision to Improve Patient Safety

Evidence linking sleep deprivation to a higher risk of medical errors prompted limits in 2003 on the hours per week that medical residents could work at U.S. hospitals.

The 80-hour work week, enacted and monitored by the Accreditation Council for Graduate Medical Education (ACGME), also allows residents to work a maximum 30-hour shift. During these shifts, residents can treat patients for 24 hours and take part in training or patient handoff activities for the remaining 6 hours.

Five years after the rules were enacted, a new report from the Institute of Medicine (IOM, 2008) concludes that these measures did not sufficiently protect residents from acute and chronic fatigue, thus continuing to put patient safety at risk. The report calls for new measures that create protected periods for sleep and increased supervision of work hour limits.

Funded by my agency, the Agency for Healthcare Research and Quality (AHRQ), the IOM report is the result of a 15-month study by an expert committee that reviewed the relationship between residents’ work schedules, their teaching environment, and the quality of care patients receive. It confirms scientific evidence that shows that acutely and chronically fatigued residents are more likely to make mistakes.

Medical Community Reaction
Opinions in the medical community have been mixed about the impact of the 2003 rule and on the changes called for in IOM’s new report.

One-third (33%) of 2,567 respondents to a 2008 poll in the New England Journal of Medicine (Iglehart, 2008) said that the current 80-hour work week limits were good for patients and residents, while nearly half (48%) said those hours were too long. The remainder (19%) said no limits should be put on residents’ work hours.

Some neurosurgery groups have expressed concerns about the IOM’s new recommendations, saying they could reduce the time residents need to attain needed experience and expertise.

“Unless the residency training period is extended considerably, residents in neurosurgery will receive 25% to 50% less training than residents received prior to 2003,” said M. Sean Grady, MD, who chairs the American Board of Neurosurgery and the neurosurgery department at the University of Pennsylvania (Jeffrey, 2008).

IOM’s Recommendations
The IOM report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, proposes specific changes in how shifts are structured to address acute and chronic fatigue.

Shifts that extend beyond 16 hours should include a 5-hour period of uninterrupted, continuous sleep between 10 p.m. and 8 a.m., during which residents are free from all work and call responsibilities, the report advises. Residents should not admit new patients after 16 hours on duty; night-shift duty should not be permitted to exceed four consecutive nights, the report recommended.

Other key recommendations from the IOM report include:

  • Increased supervision of work hours. Lack of adherence to current limits is common and often under-reported. For example, the ACGME reports that only 3% of the 6,837 citations given to teaching programs in 2007-2008 were for non-compliance with duty hours, a finding that has been consistent since these limits were enacted. (ACGME) Periodic independent reviews and stronger protections for residents and others who report a lack of adherence to current work hour restrictions should be developed.
  • Stronger moonlighting restrictions. The IOM report recommends internal and external moonlighting count against the 80-hour weekly limit, because moonlighting outside residency training affects periods specifically designed for rest and sleep.
  • Safe transportation provided by hospitals to residents who are too fatigued to drive home. AHRQ-funded research shows that residents more than double their risk of driving accidents when they drive home after working extended shifts.
  • Increased resident training on better communication during handoffs. Handoffs, which occur when clinicians transition care responsibility to other health care providers, are likely to increase with shorter resident shifts. In some cases, multiple handovers could add to the risk for adverse events unless a structured team approach is used.
  • Increased involvement of residents in patient safety activities and adverse event reporting. Such involvement could greatly increase the resident’s educational experience, according to the report.

Meeting Multiple Objectives
Without question, providing the rigorous educational experience that residents require, modifying their schedules to address acute and chronic fatigue, and involving them in new training and patient safety activities presents challenges to teaching programs. Concern about how to meet these multiple objectives in the limited timeframe of a medical residency program underlies some of the objections to the IOM’s new recommendations.

At the same time, the medical community should not lose sight of the scientific evidence that demonstrates the serious patient safety risks of sleep deprivation, risks that are compounded by the increasing complexity of medical practice.

For example, an AHRQ-funded study conducted by Harvard Medical School’s Christopher Landrigan, MPH, MD, (2004) found that sleep-deprived residents working in hospital intensive care units (ICUs) often failed to perform a thorough history and physical examination. Residents who worked beyond 18 consecutive hours also had five times as many serious diagnostic errors as those who ended their shifts earlier.

The effect of sleep deprivation in hospital ICUs may be more significant than in other care settings. However, a lack of evidence to support the unique concerns of particular specialties prevented the IOM committee from tailoring its recommendations for particular specialties.

Even if that were possible, the limits of human performance in the face of continued sleep deprivation would argue against such exceptions. “Residents in all specialties are human beings,” noted Emory University Chancellor Michael M.E. Johns, MD, (Jeffrey, 2008) who chaired the IOM committee.

AHRQ’s Teamwork, Patient Safety Tools
To help hospitals assess and improve their teamwork and patient safety culture, AHRQ has developed evidence-based tools that can assess an organization’s current performance and monitor changes over time.

Patient safety culture surveys developed by AHRQ can aid hospitals, nursing homes, and medical offices in assessing and improving their patient safety performance (AHRQ, 2009). The tools can provide a baseline for organizations, track changes over time, and evaluate the impact of patient safety interventions.

Results from nearly 400 hospitals are contained in the 2008 hospital database report and can be used as benchmarks in establishing a culture of safety. A survey now under development will address patient safety culture in ambulatory medical offices.

TeamSTEPPS™ was developed by AHRQ and the U.S. Department of Defense in 2006. It is an evidenced-based teamwork system that aims to improve communication among health care professionals using a comprehensive set of training curricula (http://teamstepps.ahrq.goc/index.htm).

To help implement this system, four resource centers are conducting master trainer training courses that will continue through September 2009. The centers are: Duke Medical Center, Durham, NC; Carilion Clinic, Roanoke, VA; University of Minnesota Fairview Medical Center, Minneapolis, MN; and Creighton University Medical Center, Omaha, NE.

The IOM’s new report confirmed issues that many in the patient safety community have considered for some time — the 2003 work hour limits are not sufficient to prevent acute and chronic fatigue, work hour violations occur too often, and residents need more involvement in teamwork and patient safety activities.

At the same time, the findings demonstrate that more work is needed to change the culture of medical training. Evidence-based findings about the impact of sleep deprivation on human performance cannot take a back seat to the demanding training requirements of certain specialties.

Balancing these objectives is not easy and will require shifts in organizational and individual thinking. (Drazen, 2004). By adopting revised staffing models and putting a greater emphasis on teamwork, communication, and patient safety activities, we can develop approaches in our teaching hospitals and other care settings that will better serve the next generation of physicians and the patients they treat.

Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at George Washington University School of Medicine in Washington, DC. She may be contacted at carolyn.clancy@ahrq.hhs.gov.


Accreditation Council for Academic Graduate Medical Education. The ACGME’s approach to limit residents’ duty hours, 2007-08: A summary of achievements for the fifth year under the common requirements. Accessed February 10, 2009, at http://www.acgme.org/acWebsite/dutyhours/dh_achievesum0708.pdf

Agency for Healthcare Research and Quality. (2009, January). Patient safety culture surveys. Rockville, MD: Author. Accessed February 10, 2009, at http://www.ahrq.gov/qual/hospculture/

Drazen, J. M. (2004, October 28). Awake and informed. New England Journal of Medicine, 351(18), 1884.

Iglehart, J. K. (2008, December 24). Perspective forum: Residents duty hours and the IOM Report. New England Journal of Medicine. Accessed February 10, 2009, at http://www.nejm.org/perspective-forum/residents-hours-report/

Institute of Medicine. (2008, December). Resident duty hours: Enhancing sleep, supervision, and safety. Washington, DC: National Academies Press. Accessed February 10, 2009, at http://www.iom.edu/?ID=60449

Jeffrey, S. (2008, December 9). Neurosurgery associations push back on IOM resident work-hour report. Medscape Medical News. Available to registered users at http://www.medscape.com/viewarticle/585002. Accessed February 10, 2009.

Landrigan, C. P., Rothschild, J. M., Cronin, J. W., et al. (2004, October 28). Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine, 351(18), 1838-1848.