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
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
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.,
"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
"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
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
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>.▪