Friday, August 27, 2010

Analyzing the July effect

A medical resident guest blogging at Kevin MD notes:

According to an article published in the Journal of General Internal Medicine, counties with teaching medical hospitals experienced a 10% increase in fatal medication errors as compared to counties without teaching medical hospitals.


Of course we've long suspected this. Apparently having better supervision, better hours, CPOE and UpToDate everywhere at the point of care hasn't solved the problem. In fact, CPOE could be making it worse. When new interns arrive, if they've come from another school, as likely as not they have to use an EMR they're not familiar with, having had only a brief orientation period and no secretarial training.

4 comments:

Michael Kirsch, M.D. said...

The first day of my internship, I was asked to pronounce a patient dead. I had never seen him, he was on my assigned list. Except for the medical school cadaver, I had never seen a dead person. Was this guy really dead? How do I tell? That's the level of clinical acumen we July interns had.

Orac said...

Reading the study, four words came to mind: Holy ecological fallacy, Batman!

http://scienceblogs.com/insolence/2010/06/dont_get_sick_in_july_revisited.php

Sorry, but I wasn't as impressed with this paper. Lots of problems, not the least of which is the ecological fallacy, but also the fact that medication errors are a systemic problem that depends a lot more on the system in place to prevent them than they do on the residents.

Orac said...

Reading the study, four words came to mind: Holy ecological fallacy, Batman!

http://scienceblogs.com/insolence/2010/06/dont_get_sick_in_july_revisited.php

Sorry, but I wasn't as impressed with this paper. Lots of problems, not the least of which is the ecological fallacy, but also the fact that medication errors are a systemic problem that depends a lot more on the system in place to prevent them than they do on the residents.

R. W. Donnell said...

Orac,
I had not read your post until now and did not see the full text of the paper (I don't think I had access to it). A few follow up observations.

It had escaped my notice that the study went back to 1979, so it says little about whether better resident supervision or the EMR have helped.

There's no reason to think that system based med errors should increase when you have less experienced house staff taking care of patients.

But there's another type of med error that you might expect to increase, which is judgment based medication error. So maybe the intern wrings the heart failure patient out with lasix without paying attention to her potassium, and she suffers cardiac arrest from ventricular arrhythmia. Maybe, in the tachycardic septic patient, dopamine is chosen, resulting in a serious arrhythmia, when norepinephrine would have been a better choice according to most literature. Or maybe heparin is given for a weak indication and the patient bleeds. The "systems" we have in place now are not very good at intercepting these types of judgment errors. One might argue that these aren't really medication errors. I don't know how errors were adjudicated in this paper, but I wonder if such judgment errors were considered medication errors.

I agree that there are problems out the wazoo with this paper. We can't really claim to have research quality evidence for the July effect. On the other hand, very strong anecdotal evidence from my training days (and apparently from Dr. Kirsch's) suggests that it's real.