Rate of undesirable events at beginning of academic year: retrospective cohort study

Rate of undesirable events at beginning of academic year: retrospective cohort study.
Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. BMJ. 2009;339:b3974.

The so-called July phenomenon, in which errors are supposedly more common in July due to an influx of inexperienced residents and students, has long been a source of gallows humor in hospitals. Although prior studies have reached mixed conclusions, this Australian study of anesthesia errors did find a significant increase in preventable adverse events for procedures performed by trainees during the first 4 months of the academic year. Interestingly, error rates were higher for trainees at all levels, not just first-year residents. This finding implies that underlying systems issues as well as clinical inexperience resulted in adverse events. An accompanying editorial calls for revising training models in order to provide adequate supervision and support for new trainees. A case of inadvertent hypoglycemia resulting from an intern's lack of familiarity with insulin ordering at his new hospital is discussed in an AHRQ WebM&M commentary.

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Published 13 October 2009, doi:10.1136/bmj.b3974
Cite this as: BMJ 2009;339:b3974

Research
Rate of undesirable events at beginning of academic year: retrospective cohort study
Guy Haller, consultant1,4, Paul S Myles, professor and director2, Patrick Taffé, biostatistician3, Thomas V Perneger, professor and head of division4, Christopher L Wu, associate professor5

1 Department of Anaesthesia, Pharmacology and Intensive Care, Geneva University Hospital, University of Geneva, 1211 Geneva, Switzerland, 2 Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Monash University, Prahran, Vic 3181, Australia, 3 Institute of Social and Preventive Medicine, 1005 Lausanne, Switzerland, 4 Division of Clinical Epidemiology, Geneva University Hospital, 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore 21205, MD, USA

Correspondence to: Guy Haller Guy.Haller@hcuge.ch

Objective To determine whether an increase in the rate of undesirable events occurs after care provided by trainees at the beginning of the academic year.
Design Retrospective cohort study using administrative and patient record data.

Setting University affiliated hospital in Melbourne, Australia.

Participants 19 560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000).

Main outcome measures Absolute event rates, absolute rate reduction, and rate ratios of undesirable events.

Results The rate of undesirable events was higher at the beginning of the academic year compared with the rest of the year (absolute event rate 137 v 107 per 1000 patient hours, relative rate reduction 28%, P<0.001). The overall adjusted rate ratio for undesirable events was 1.40, 95% confidence interval 1.24 to 1.58. This excess risk was seen for all residents, regardless of their level of seniority. The excess risk decreased progressively after the first month, and the trend disappeared fully after the fourth month of the year (rate ratio for fourth month 1.21, 0.93 to 1.57). The most important decreases were for central and peripheral nerve injuries (relative difference 82%), inadequate oxygenation of the patient (66%), vomiting/aspiration in theatre (53%), and technical failures of tracheal tube placement (49%).

Conclusions The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.


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