The Effect of Intensive Inpatient Attending Supervision on Medical Errors, Patient Safety and Resident Education

Study Overview
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Brief Summary
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Randomized cross over trial investigating the effect of intensive attending supervision of residents caring for inpatients on the medical service on both patient safety and educational outcomes. Hypothesis: increased attending supervision would improve patient safety and resident education.

Detailed Description
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Background While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending supervision on patient safety and education. 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.

Official Title
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The Effect of Intensive Inpatient Attending Supervision on Medical Errors, Patient Safety and Resident Education

Conditions
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Focus of Study is on Graduate Medical Education Supervision

Intervention / Treatment
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* Other: Enhanged Attending Supervision
* Other: Standard of Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria Teaching attending on the medicine service at Massachusetts General Hospital Resident physician on the medical service at Massachusetts General Hospital Exclusion Criteria Faculty unable to complete both control and intervention arms of the study. Faculty unwilling to participate Residents unwilling to participate

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: We 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. Resident education was evaluated via a time motion study to assess resident participation on rounds and surveys to measure resident and attending educational ratings.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Intervention Arm<br>Attendings on the interventional arm attended daily work rounds with the resident teams in addition to established work rounds on the previously admitted patients on the care team. | Other: Enhanged Attending Supervision<br>* Attendings were randomized at the start of the study to begin in the enhanced supervision arm where they attended resident work rounds. They then crossed over to the control arm where they did not attend work rounds. The outcomes were assessed between the two periods during which the attending participated in the study; attending work rounds vs. not attending work rounds.<br>|
| Placebo Comparator: Control Arm<br>Attendings crossed over to the control arm in which they did not attend work rounds with the team and only say new admissions with the resident team. This was usual care. | Other: Standard of Care<br>* Attendings participated directly in new patient rounds but did not see patients previously known to the team with the residents.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Measurement of the rate of medical errors defined as preventable adverse events and near misses. Patient Safety Outcome | Using a previously validated protocol (PMID:24871238) to assess these outcomes, 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. Medical Error rates are reports as number of events per 1,000 patient days | 9 months | 
| Resident Engagement on Rounds: Educational Outcome | Time motion study of the amount of time residents and faculty speak during rounds. Time was measured by a research assistant using a Microsoft access program embedded on an IPAD that recorded length of time. Time measurement outcomes are reported in minutes | 9 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Resident and Faculty Perception of Education, Educational Outcome | A 20 question survey based on prior literature (PMID: 25340363) 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. | 9 months | 
| Deaths, Patient Safety Outcome | Hospital collected data on the number of medical patients who died during the study | 9 months | 
| Transfers to the Intensive Care Unit, Patient Safety Outcome | Hospital collected data on the number of medical patients who were transferred to the intensive care unit | 9 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Graduate Medical Education, Attending Supervision of Residents, Patient Safety