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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
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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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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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