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Cheryl Ulmer, Dianne Miller Wolman, Michael M. E. Johns, Editors Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP233200700003T between the National Academy of Sciences and the Agency for Healthcare Research and Quality. Any opinions, find- ings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Resident duty hours : enhancing sleep, supervision, and safety / Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety ; editors, Cheryl Ulmer, Dianne Miller Wolman, Michael M.E. Johns. p. ; cm. Includes bibliographical references and index. ISBN 978-0-309-12776-9 (hardcover) 1. Residents (Medicine)—United States. 2. Fatigue. 3. Sleep deprivation. 4. Hours of labor. 5. Hospitals—United States—Safety measures. 6. Medical errors. I. Ulmer, Cheryl. II. Wolman, Dianne Miller. III. Johns, Michael M. E. IV. Institute of Medicine (U.S.). Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. [DNLM: 1. Internship and Residency—standards—United States—Guideline. 2. Education, Medical, Graduate--standards—United States—Guideline. 3. Medical Errors— prevention & control—United States—Guideline. 4. Patient Care—standards—United States—Guideline. 5. Sleep Deprivation—prevention & control—United States—Guideline. 6. Work Schedule Tolerance—United States—Guideline. W 20 R4335 2009] RA972.R465 2009 610.71’55—dc22 2009003372 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Photo Credit: Front cover reprinted with permission from Emory University Photo/Video, 2008. Suggested citation: IOM (Institute of Medicine). 2009. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON OPTIMIZING GRADUATE MEDICAL TRAINEE (RESIDENT) HOURS AND WORK SCHEDULES TO IMPROVE PATIENT SAFETY MICHAEL M. E. JOHNS (Chair), Chancellor, Emory University, Atlanta, GA JAMES BAGIAN, Chief Patient Safety Officer, Director, VA National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, MI JAYANTA BHATTACHARYA, Assistant Professor, Center for Primary Care and Outcomes Research, Stanford University, CA MAUREEN BISOGNANO, Executive Vice President and Chief Operating Officer (COO), Institute for Healthcare Improvement, Cambridge, MA PASCALE CARAYON, Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering, and Director, Center for Quality and Productivity Improvement, University of Wisconsin–Madison JORDAN J. COHEN, Professor, Medicine and Public Health, George Washington University, Washington, DC DAVID F. DINGES, Professor and Chief, Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia JAVIER A. GONZALEZ DEL REY, Professor of Pediatrics and Director, Pediatric Residency Programs, Cincinnati Children’s Hospital Medical Center, Ohio PETER J. KOLESAR, Professor Emeritus and Research Director, Deming Center for Quality, Productivity and Competitiveness, Columbia University, New York, NY BRIAN W. LINDBERG, Executive Director, Consumer Coalition for Quality Health Care, Washington, DC KENNETH M. LUDMERER, Professor of Medicine and Professor of History, Washington University, St. Louis, MO DANIEL MUNOZ, Fellow, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD CHRISTOPHER S. PARSHURAM, Director, Center for Safety Research, Assistant Professor, Department of Critical Care Medicine, Hospital for Sick Children, and Departments of Paediatrics, Health Policy Management and Evaluation, University of Toronto, ON, Canada ANN E. ROGERS, Associate Professor, University of Pennsylvania School of Nursing, Philadelphia DENISE M. ROUSSEAU, H. J. Heinz II Professor of Organizational Behavior and Public Policy and Director, Project of Evidence-Based Organizational Practices, Carnegie Mellon University, Pittsburgh, PA EDUARDO SALAS, Pegasus Professor and University Trustee Chair, Department of Psychology and Institute for Simulation and Training, University of Central Florida, Orlando BRUCE SIEGEL, Director, Center for Health Care Quality, George Washington University School of Public Health and Health Services, Washington, DC v

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IOM Study Staff Cheryl Ulmer, Study Co-director Dianne Miller Wolman, Study Co-director Michelle Bruno, Research Associate Cassandra Cacace, Senior Program Assistant Roger Herdman, Director, Board on Health Care Services vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: BARBARA LEE BASS, Methodist Institute for Technology, Innovation & Education (MITIE)TM, Department of Surgery, The Methodist Hospital, Houston, TX, and Weill Medical College of Cornell University, New York LINDA EMANUEL, Buehler Center on Aging, Health and Society, Feinberg School of Medicine, Northwestern University, Chicago, IL KATHLYN E. FLETCHER, Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI DORRIE K. FONTAINE, University of Virginia School of Nursing, Charlottesville, VA ROBERT L. HELMREICH, Human Factors Research Project, The University of Texas at Austin, Austin, TX STEVEN K. HOWARD, VA Palo Alto Health Care System Anesthesia Service and Stanford University School of Medicine Anesthesia Service, Palo Alto, CA vii

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viii REVIEWERS SANDEEP JAUHAR, Heart Failure Program, Long Island Jewish Medical Center, New York, NY ERIC B. LARSON, Group Health Center for Health Studies, Seattle, WA ARTHUR A. LEVIN, Center for Medical Consumers, New York, NY STEVEN LIPSTEIN, BJC HealthCare, St. Louis, MO ALAN R. NELSON, American College of Physicians, Fairfax, VA TERRANCE D. PEABODY, Section of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Medical Center, Chicago, IL DEBORAH E. POWELL, University of Minnesota Medical School, Minneapolis, MN RANGARAJ RAMANUJAN, Owen Graduate School of Management, Vanderbilt University, Nashville, TN ROGER R. ROSA, National Institute for Occupational Safety and Health, Washington, DC DAVID P. STEVENS, Quality Literature Program, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH KEVIN VOLPP, Center for Health Equity Research and Promotion (CHERP), Philadelphia VA Medical Center, and Center on Health Incentives, Leonard Davis Institute for Health Economics, University of Pennsylvania School of Medicine and the Wharton School, Philadelphia, PA JAMES K. WALSH, Sleep Medicine and Research Center, St. Luke’s Hospital, Chesterfield, MO Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Donald Steinwachs, Health Services Research and Development Center, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hop- kins University, Baltimore, MD, and Adel A. F. Mahmoud, Woodrow Wilson School and Department of Molecular Biology, Princeton Univer- sity, Princeton, NJ. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully con- sidered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Foreword Most physicians can recall moments of total exhaustion during their residency, when they had been working steadily on patients around the clock, and other moments of total exhilaration, such as when they realized a critically ill patient would pull through. The intense residency learn- ing period that follows medical school is an integral part of a physician’s professional development and essential preparation for clinical practice. Physicians may have very strong feelings about how well our own training experience prepared us and ways in which it could have been improved. We may have memories of mistakes we made during training and wonder whether they could have been prevented had we consulted the attending earlier, received more information during the handover, remembered a criti- cal test, or correctly calculated the dose of medication. Today, with deeper appreciation of risks to patients, we may wonder how the work environ- ment of residents can be redesigned to enhance patient safety and whether this can be done while preserving or, even better, while enhancing the learn- ing to be a doctor that is at the heart of any residency training program. The Institute of Medicine (IOM) appointed the Committee on Opti- mizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, at the request of Congress and the Agency for Healthcare Research and Quality, to weigh these questions. Specifically, the committee examined whether residents’ duty hours and schedules could be improved to reduce sleep deprivation, performance degradation, and the risk of error, while ensuring that residents have sufficient time to receive the necessary training and experience. The IOM has a history of reports on medical education, training, and the healthcare workforce, as well as ix

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x FOREWORD a long-standing concern for patient safety. The current committee builds on the Quality Chasm series of reports, beginning with To Err Is Human in 1999 and Crossing the Quality Chasm in 2001, that produced many evidence-based recommendations to inform medical education, safety, and work systems redesign. This study stirred considerable interest, concern, and debate among physician educators, residents, and patient interest groups. The first set of common national duty hour standards for all types of residencies was implemented just 5 years ago, in 2003. Although limited data directly assess the impact of these regulations, the committee was able to utilize a robust body of evidence on sleep, fatigue, and human performance. Importantly, the committee considered various aspects of residency beyond duty hours, such as the educational process and work environment, in search of ways to improve the learning experience for residents and maximize the value to patients of their hours on duty. I am grateful to the committee and to the staff who supported its work for their conscientious deliberation and concrete guidance. I hope this re- port stimulates a spirited discussion and prompts needed improvements in residency training. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine November 2008

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Preface Graduate medical education (GME), also known as residency train- ing, has evolved significantly over the last century since first initiated in its modern form at the Johns Hopkins Hospital. The processes of accreditation of training programs by the Accreditation Council for Graduate Medical Education (ACGME) and of certification of graduates by specialty certify- ing boards are also progressively evolving. In 2003, the ACGME promul- gated national guidelines regarding resident duty (work) hours that, for the first time across all specialties, limited the number of hours per week that a resident could work to the same common limits. Since then there has been much interest in the extent and effects of implementation of the 2003 guidelines, as well as continuing concerns about resident fatigue and its relationship to patient safety. This committee was asked to synthesize evidence on the relationship of medical resident duty hours and schedules to healthcare safety and to develop strategies for implementing optimal resident work schedules. The committee understood that proposed strategies must take into account the learning and experience that residents must achieve during their training, with recommendations structured to optimize both the quality of care and the educational objectives. The committee includes experts with experience in medical care and medical education as well as a variety of disciplines such as organization change, patient safety, and human factors engineering. Through scheduled workshops and written submissions, the committee was privileged to hear from a wide array of knowledgeable and interested individuals and organi- zations who helped broaden our perspective on the issues. xi

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xvi ACKNOWLEDGMENTS L. Toni Lewis, Committee of Bernard F. Ribeiro, The Royal Interns and Residents/SEIU College of Surgeons of England Richard J. Liekweg, University of Mark R. Rosekind, Alertness California–San Diego Medical Solutions Center Paul Schyve, Joint Commission Peter Lurie, Public Citizen Arpana Vidyarthi, University of Thomas Nasca, Accreditation California–San Francisco School Council for Graduate Medical of Medicine Education Kevin Volpp, University of Penn- Mark Noah, Cedars-Sinai Medical sylvania Wharton School of Center Business Lawrence M. Opas, Los Angeles Steven Weinberger, American County and University of South- College of Physicians ern California Medical Center Debra Weinstein, Association of Ingrid Philibert, Accreditation American Medical Colleges Council for Graduate Medical Kevin Weiss, American Board of Education Medical Specialties Sunny Ramchandani, Residents Tom Whalen, American College of and Fellows Section, American Surgeons Medical Association We also thank the following people who provided essential informa- tion and generously shared their expertise and time to help the committee: Carlo DiMarco, American Osteopathic Association; Karen Fisher, David Longnecker, Erica Steinmetz, and Sunny Yoder, Association of American Medical Colleges; Daniel Goodenberger, University of Nevada School of Medicine; Jennifer Jolly, Gerald Maguire, and Christopher Wall, University of California–Irvine School of Medicine; Alexander Khalessi, University of Southern California; Lee Learman, University of California–San Francisco; Adam Levine and Paul Rockey, American Medical Association; Graham McMahon, Brigham and Women’s Hospital; David Meltzer, University of Chicago; David Nashel, Veterans Affairs Medical Center, Washington, DC; Susan Okie, New England Journal of Medicine; Parveen Parmar, University of California–Los Angeles/Olive View Hospital; Terrance Peabody and Vincent Pellegrini, American Orthopaedic Association; Ingrid Philibert, Ac- creditation Council for Graduate Medical Education; Deborah Powell, New Zealand Resident Doctors Association; Meilan and Michael Rutter, Cincin- nati Children’s Hospital Medical Center; Sandy Shea, Committee on Interns and Residents–Service Employees International Union; Robert Wachter, University of California–San Francisco; Veronica Wilbur, IPRO; and Arezou Yaghoubian, University of California–Los Angeles Medical Center. Consultants Teryl Nuckols and Jose Escarce, both of the David Geffen School of Medicine at University of California–Los Angeles and RAND,

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xvii ACKNOWLEDGMENTS were generous in assisting the committee in analyzing the potential costs of its recommendations, and Daniel Polsky, University of Pennsylvania, reviewed their work for the committee. Funding for this study was provided by the Agency for Healthcare Research and Quality (AHRQ). The committee appreciates its financial support for the project as well as the substantive support from AHRQ staff, Eileen Hogan and James Battles. Many within the Institute of Medicine (IOM) were helpful during the study process and of assistance to the study staff. The project staff benefited from the assistance of two IOM interns, Adam Schickedanz, University of California–San Francisco School of Medicine, and Melissa Crocker, Children’s National Medical Center, and the contributions of Ann Page, Michele Orza, and Samantha Chao at the initiation of the project. The staff would especially like to thank Clyde Behney, Patrick Burke, Linda Kilroy, Bill McLeod, Abbey Meltzer, Judith Salerno, Bronwyn Schrecker-Jamrock, Christine Stencel, Janet Stoll, Lauren Tobias, Jackie Turner, and Harvey Fineberg.

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Contents ABSTRACT 1 SUMMARY 5 1 BACKGROUND AND OVERVIEW 27 Charge to Committee, 29 Graduate Medical Training, 30 Duty Hour Demands in the Medical Profession, 34 Scope and Organization of Report, 36 References, 42 2 CURRENT DUTY HOURS AND MONITORING ADHERENCE 47 Setting Duty Hour Limits, 48 Adapting to 2003 Duty Hours, 55 Duty Hours in Selected Industries, 65 Monitoring Duty Hours, 69 References, 83 3 ADAPTING THE RESIDENT EDUCATIONAL AND WORK ENVIRONMENT TO DUTY HOUR LIMITS 89 Resident Educational and Work Systems, 90 Redesigning Resident Work and Workload, 101 Changes in Response to Duty Hour Limits, 105 Costs of Adapting to the 2003 Duty Hour Limits, 114 References, 115 xix

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xx CONTENTS 4 IMPROVING THE RESIDENT LEARNING ENVIRONMENT 125 Educational Principles, 126 Impact of 2003 Limits on Educational Outcomes, 141 Redesigning Education and Educational Innovations, 145 Conclusion, 149 References, 150 5 IMPACT OF DUTY HOURS ON RESIDENT WELL-BEING 159 Resident Safety, 160 Resident Well-Being and Quality of Life, 165 Conclusion, 174 References, 175 6 CONTRIBUTORS TO ERROR IN THE TRAINING ENVIRONMENT 179 Measuring Hospital-Based Error Rates and Resident Involvement, 180 Fatigue as a Contributor to Error, 188 Impact of Reduced Duty Hours on Error Rates and Patient Safety, 193 Other Contributors to Error, 205 Summary, 209 References, 211 7 STRATEGIES TO REDUCE FATIGUE RISK IN RESIDENT WORK SCHEDULES 217 Fatigue, Work Hours, and Sleep Loss, 218 Need for Sleep, 219 Effects of Acute Sleep Deprivation on Human Performance, 222 Acute Sleep Deprivation and Resident Performance, 223 Acute Sleep Loss Plus Inexperience in First-Year Residents, 225 Work Duration and Risk, 225 Prevention of Acute Sleep Deprivation, 227 Improving Adherence to Use of Protected Sleep Periods, 231 Prevention of Chronic Sleep Deprivation, 232 Approaches to Prevent Chronic Sleep Loss, 234 Recovery Sleep, 237 Adjustments to the 2003 Resident Duty Hour Limits, 241 Additional Considerations Underpinning Recommendation 7-1, 243 Resident Moonlighting, 251 References, 252

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xxi CONTENTS 8 SYSTEM STRATEGIES TO IMPROVE PATIENT SAFETY AND ERROR PREVENTION 263 Learning in a Culture of Safety, 264 Reducing Errors by Improving Handovers, 266 Handover Interventions, 269 Training Doctors and Error Reporting, 277 Developing a Team Culture, 282 Conclusion, 286 References, 287 9 RESOURCES TO IMPLEMENT IMPROVEMENTS FOR PATIENT SAFETY AND RESIDENT TRAINING 295 Cost Implications of Changes to Duty Hours, 298 Funding the Committee’s Recommendations, 315 Workforce Implications, 318 A Phased Implementation of Duty Hours, Its Evaluation, and Further Research, 320 References, 325 APPENDIXES A Statement of Task 329 B Comparison of Select Scheduling Possibilities Under Committee Recommendations and Under 2003 ACGME Duty Hour Rules 331 C International Experiences Limiting Resident Duty Hours 339 D Glossary, Acronyms, and Abbreviations 363 E Committee Member Biographies 371 F Public Meeting Agendas 379 INDEX 385

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Boxes, Figures, and Tables Summary Table S-1 Comparison of IOM Committee Adjustments to Current ACGME Duty Hour Limits, 13 Chapter 1 Table 1-1 U.S. Resident Training Programs by Specialty and Resident Physicians on Duty, 33 Chapter 2 Tables 2-1 Evolution of Duty Hour Limits, 49 2-2 Comparison of Duty Hour Provisions, 52 2-3 Average Reported Weekly Work Hours and Percentage of PGY-1 and PGY-2 Residents Working Over Proposed 80-Hour Limit by Specialty, 1998-1999 National Survey, 56 2-4A Comparison of Reported Duty Hour Violation Rates by Facility and Program, 59 2-4B Comparison of Reported Duty Hour Violation Rates by Residents, 60 2-5 Duty Hour Violations in New York State by Specialty (2006- 2007), 63 xxiii

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xxiv BOXES, FIGURES, AND TABLES 2-6 Federally Mandated Work Hour Limitations for U.S. Transportation Modes and ACGME Duty Hours, 66 Chapter 3 Figure 3-1 Representative work hours during a single week for the whole team of interns during the traditional schedule (Panel A) and the intervention schedule (Panel B), 107 Table 3-1 Case Mix Index by Teaching Status for FY 2007, 92 Chapter 4 Figure 4-1 View of 111 key clinical faculty on the effect of duty hour regulations on faculty workload satisfaction, 133 Chapter 6 Box 6-1 Taxonomy of Errors, 182 Chapter 7 Figures 7-1 Relationship of residents’ average weekly sleep to average weekly hours of work, 221 7-2 Repeated nights of sleep loss result in cumulative cognitive impairment, 233 Table 7-1 Comparison of IOM Committee Adjustments to Current ACGME Duty Hour Limits, 245 Chapter 8 Boxes 8-1 National Patient Safety Goal 2: Improve the Effectiveness of Communication Among Caregivers, 270 8-2 The Five Core Components of Teamwork, 284 Chapter 9 Tables 9-1 Sources of GME Funding, 299

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xxv BOXES, FIGURES, AND TABLES 9-2 Methods: Application of Substitution Strategies to Base Case Scenario, 306 9-3 Results: Costs of Hiring Other Providers to Assume Excess Resident Work, Base Case Scenario (2006), 308 9-4 Results: Reducing Resident Duty Hours by Increasing Number of Residents Nationally, 310 9-5 Sensitivity Analyses, 312 9-6 Results: Net Costs of Proposed Changes, Considering Costs of Resident Substitution and Possible Changes in PAEs (2006), 316 Figure 9-1 Median margins of hospitals by teaching status, 301 Appendix B Tables B-1a Possible Extended Duty (q4) Monthly Schedule for a Single Resident Under Committee Proposal, 332 B-1b Possible Extended Duty (q4) Monthly Schedule for a Single Resident Under Current ACGME Rules, 333 B-2a Possible Extended Duty (q5) Monthly Schedule for a Single Resident Under Committee Proposal, 334 B-2b Possible Extended Duty (q5) Monthly Schedule for a Single Resident Under Current ACGME Rules, 335 B-3a Possible 10-Hour Daytime Schedule for a Single Resident Under Committee Proposal, 336 B-3b Possible 10-Hour Daytime Schedule for a Single Resident Under Current ACGME Rules, 336 B-4a Possible 12-Hour Nighttime Schedule for a Single Resident Under Committee Proposal, 337 B-4b Possible 12-Hour Nighttime Schedule for a Single Resident Under Current ACGME Rules, 337 Appendix C Tables C-1 Resident Duty Hour Regulations in Various Countries, 2008, 341 C-2 International Comparison of Adverse Events (AE) and Preventable Adverse Events (PAEs), 343

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