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Education and Training
Medication Errors More Common in Depressed Residents
Psychiatric News
Volume 43 Number 5 page 12-31

Pediatric residents identified as depressed by a validated screening tool made significantly more medication errors during a two-month period than residents who were not depressed or who were deemed "burnt out."

That was the finding from a prospective study of 123 pediatric residents in three institutions: Children's Hospital Boston; Lucile Packard Children's Hospital in Palo Alto, Calif.; and the Children's National Medical Center in Washington, D.C. The report appeared in the February 7 British Medical Journal (BMJ).

Twenty percent of the residents were identified as depressed by the Harvard National Depression Screening Day Scale; those depressed residents made 6.2 times as many medication errors as did nondepressed residents.

A medication error was defined as any error in the ordering, transcription, or administration of a medication, whether harmful or trivial. Errors were classified as a "potential adverse event" or "error with little potential for harm."

None of the errors resulted in harm to patients.

Examples of potential adverse drug events included an order written for intravenous potassium chloride bolus for a patient with cancer but with no concentration or rate provided and an order written for morphine on the wrong patient's order form. Errors with little potential for harm included an order written for Tylenol for a patient with osteomyelitis, with no frequency provided; and an order written for cefepime for a patient with cystic fibrosis with no route provided.

Participants logged their daily work and sleep hours from mid-May through the end of June 2003. They also completed a validated questionnaire on their health, quality of life, and self-reported medical errors.

A team of nurses and physicians was trained in the collection of data on medication errors using standardized methods. Data collectors were blinded as to whether residents were burnt out or depressed. They collected daily reports of all medication errors that occurred on studied wards from clinical staff and reviewed all charts and medication orders using structured data forms.

Though the sample size was small and the precise relationship between depression and medication errors is unclear, the results should be a signal to training directors, said study senior author Christopher Landrigan, M.D., M.P.H.FIG1

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"In the world of patient safety, a sixfold increase in errors is extremely significant," Landrigan told Psychiatric News." Larger-scale studies need to be done in multiple institutions to substantiate the relationship we found between depression and errors, but if it holds up, it is something training directors should be alert to.

"Certainly, the rate of depression we found is a concern, and training directors need to be screening for and identifying depression among their residents," Landrigan continued. "If it does turn out that depression is as prevalent as we have found, it raises the question of what we are going to do about it. Why are residents depressed at such a high rate? And are there things we can do to detect it earlier?"

Landrigan is director of the sleep and patient safety program at Brigham and Women's Hospital in Boston.

The study was unique in exploring an area that residents are not typically eager to discuss. The rules of the study were such that those who participated and were identified as depressed could not be advised to seek treatment for their depression.

"We struggled with this, but according to the constraints of our confidentiality agreement with residents, we could only step in if it was determined that they were an immediate danger to self or others," Landrigan said. "Short of that, we could not ethically break the confidentiality agreement we made when we asked them to participate in the study."

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The 26-item Maslach burnout inventory was used to assess the prevalence of burnout. The researchers found that residents who were identified as" burnt out" did not commit more errors than did residents who were not "burnt out."

Landrigan said he believes the distinction between burnout and depression and the difference in number of errors serve to underscore the severity of depression and its impact on functioning.

The study was part of a broad assessment of the effect of new work-hour rules for training programs developed by the Accreditation Council on Graduate Medical Education (ACGME) in 2003. In 2006, Landrigan was lead author of a report in the Journal of the American Medical Association showing that there were widespread violations of the work-hour rules, across programs and specialties, one year after their implementation (Psychiatric News, October 20, 2006).

Past APA President Michelle Riba, M.D., also a past president of the Association of Directors of Psychiatric Residency Training, said the results of the BMJ study on medical errors should prompt larger studies of the subject matter, using clinical criteria for assessing depression and monitoring errors over a longer period of time.

"It is not surprising that professionals in any arena who are experiencing depression will have problems with job performance," Riba told Psychiatric News. "These results are a signal and a stimulus for all of us to think about these issues for our residents."

An abstract of "Rates of Medication Errors Among Depressed and Burnt Out Residents: Prospective Cohort Study" is posted at<www.bmj.com/cgi/content/abstract/bmj.39469.763218.BEv1>.

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