A 46-year-old man is hospitalized with diabetic ketoacidosis. He is administered intravenous fluids and an insulin drip, and laboratory testing is ordered. In the morning, the on-call physician hands off the patient to the day shift physician, who arrives an hour late due to an emergency at his nighttime moonlighting job. The handoff information includes the status of the patient and instructions to check electrolytes and calculate his anion gap. The physician performs inpatient rounds and then sees his usual clinic outpatients in the afternoon, but he neglects to check the patient's anion gap. The patient subsequently develops worsening acidosis requiring intubation for respiratory distress. Which of the following is the most likely cause of this adverse outcome?

Question

A 46-year-old man is hospitalized with diabetic ketoacidosis.  He is administered intravenous fluids and an insulin drip, and laboratory testing is ordered.  In the morning, the on-call physician hands off the patient to the day shift physician, who arrives an hour late due to an emergency at his nighttime moonlighting job.  The handoff information includes the status of the patient and instructions to check electrolytes and calculate his anion gap.  The physician performs inpatient rounds and then sees his usual clinic outpatients in the afternoon, but he neglects to check the patient's anion gap.  The patient subsequently develops worsening acidosis requiring intubation for respiratory distress.  Which of the following is the most likely cause of this adverse outcome?

Quizplus · Accepted Answer

Sleep deprivation is common among physicians and can have a profound effect on patient safety. Sleep science has demonstrated "dose-dependent" effects of sleep deprivation on physician cognitive performance and risk of medical errors. Impairments in cognitive performance and motor skills typically manifest after 17 hours of wakefulness and are comparable to those seen in an alcohol-intoxicated individual. Although the Accreditation Council for Graduate Medical Education has mandated limitations on resident work hours in response to patient safety concerns, extended work hours of attending physicians are unregulated. Physicians typically do a poor job of self-regulating their workload, often underestimate their cumulative sleep debt, and minimize its impact on their clinical skills. In this scenario, the physician has been working continuously for more than 24 hours; fatigue is the most likely contributor to his forgetting to check the patient's anion gap, which resulted in the adverse outcome. (Choices A, B, and D) There is no evidence that the physician lacks knowledge, had an excessive patient caseload, or committed an error in judgment. (Choice C) Inadequate patient handoffs carry a high risk of medical errors. Optimal patient handoffs should include a checklist of tasks and clinical status for each patient, as occurred in this case. (Choice E) Physician burnout refers to a state of emotional exhaustion, cynicism, depersonalization, and decreased sense of personal accomplishment that can result in suboptimal patient care and medical errors. Although sleep deprivation may contribute to burnout, there is no evidence that this physician's error was secondary to burnout, which often involves errors resulting from lack of concern or callousness toward patients rather than forgetfulness. Educational objective: Sleep deprivation in physicians often causes cognitive impairment, resulting in medical errors. Although mandated resident work-hour limitations are in place, it is the responsibility of all physicians to self-regulate their workloads to promote patient safety. __________ References: Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/22913912) Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers. (http://www.ncbi.nlm.nih.gov/pubmed/23116528) Sleep deprivation, physician performance, and patient safety. (http://www.ncbi.nlm.nih.gov/pubmed/19892678)

A 46-Year-Old Man Is Hospitalized with Diabetic Ketoacidosis