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Colin P. West, MD, PhD; Angelina D. Tan, BS, BA; Thomas M. Habermann, MD; Jeff A. Sloan, PhD; Tait D. Shanafelt, MD

JAMA. 2009;302(12):1294-1300.

Context  Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown.

Objective  To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics.

Design, Setting, and Participants  Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale.

Main Outcome Measures  Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures.

Results  The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P < .001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04-1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P < .001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression.

Conclusion  Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.

Author Affiliations: Division of General Internal Medicine (Dr West); Division of Biomedical Statistics and Informatics, Department of Health Sciences Research (Drs West and Sloan and Ms Tan); Department of Medicine (Drs West, Habermann, and Shanafelt); Division of Hematology (Drs Habermann and Shanafelt), Mayo Clinic, Rochester, Minnesota.

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