Fix the July Effect for incoming interns and residents

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.

First, what is the July Effect? It represents an entire transition in the hospital, during which medical students become interns, interns become senior residents, and second or third-year residents become chief residents. All of the fellows are just starting out in their specialty of choice, and there are new attendings, fresh out of residency, who have entered their chosen field. Leadership in the hospital changes all at once, and this makes for a dynamic and uncertain environment as everyone tries to adjust to their new roles.

Secondly, what are the specific effects of this phenomenon? This question is open to interpretation – the recent study suggests that one of the effects is an increase in fatal medication errors. However, mistakes in the hospital (or in any system) only occur when a series of “errors” or “oversights” are made in unison. All of the safety nets which prevent fatal medication errors must have failed. What are these safety nets?

1. Residents, fellows, and attendings should adequately supervise the new interns who are ordering medications.

2. Medication doses on the electronic ordering system should have certain restrictions.

3. Nurses are often the only staff in the hospital who have access to the medications, and we rely on them to administer them properly.

4. Interns should be educated about when to ask questions, and they should be provided with very clear guidelines for basic medication dosages. They should know where to locate appropriate dosages, whether through an online reference or the hospital pharmacy directly.

5. Pharmacy can play a role in overseeing medication orders in the computer.

This is a list of fail-safes which, if effective, minimize the risk of fatal medication errors. There are similar back-up plans in place for other fatal medical errors, including everything from cardiopulmonary resuscitation to surgical procedures. It is only when every back-up fails that an error occurs.

Thus, if the July effect is real (and it seems hard to dismiss, based on evidence and common sense), the question is not, “Whose fault is it?” Instead, the question is, “How can we strengthen the safety nets that we have or create additional ones in order to minimize these errors?”

The first and most important step is to acknowledge that these errors are happening. Just as physicians have a difficult time coming to grips with their own mortality or invincibility, they also have a difficulty time confronting their mistakes. Guilt, fear of retribution from colleagues or patients, humiliation, or even arrogance can drive physicians to sweep their errors under the rug. And these emotions only build on themselves, so that the entire community is caught in a negative cycle of denial and shame rather than constructive analysis.

The second step is to create more fail-safes if necessary. But this can only we done if we admit to our mistakes and work together, with physicians, nurses, and residents, and commit to making our hospitals safer for patients.

This anonymous medical resident blogs at A Medical Resident’s Journey.

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  • Dr Lemmon

    I remember once giving a patient 10 times the recommended dose of IV metoprolol in the ER as an intern. He did just fine. Did not even realize what I had done until a week later. Discovered it myself. Did not have to work out fine.

  • jenga

    That or just eliminate residents and interns.

  • Michael F. Mirochna, MD

    Does eliminate mean kill them, like in the “terminator” or “die hard”? I think that would be a little harsh for us.

    I’m not sure how else doctors are trained.

  • Southernmd

    Training must occur, so I agree with the humorous response above. You can’t just eliminate residents and interns or no one would ever become an attending. This is a great article, and I agree maybe some extra controls during the beginning of this period while everyone adjusts to their new roles would help control some of the risks.

    Again, the best attendings in the world were once interns themselves. It’s a necessary process to have medical school, intern year, residency and THEN be an attending.

  • http://scienceblogs.com/insolence Orac

    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, which is almost guaranteed to produce false positives, 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. In fact, looking at that paper, I’m not even sure I believe the conclusions at all.