For many years, a basic assumption has been that very long shifts for emergency room doctors (sometimes as long as 24 hours) result in lowered cognitive functions and thus more medical errors. A recent investigation, published in the 2020 Annals of Emergency Medicine Journal was done to explore that assumption.

The conclusion was surprising to many: to a large extent, longer shifts by themselves did not result in more medical errors. A more significant factor was the clinical workload during the doctor’s shift. Another major factor was the number of patient “hand-offs” in which the doctor participated. A hand-off occurs when a patient is transferred from one department or physician to another. A typical example is the transfer of an ER patient for admission to the hospital under the care of a hospitalist or a subsequent transfer to a surgeon or other specialist. 

In emergency departments that decreased the shift length for its doctor, the conclusion was that “despite improvement in sleep and neurobehavioral performance, patient safety decreased.” That suggested that medical mistakes did not occur with more rest and consequent cognitive capacity to make good decisions. The suggestion is that, with longer shifts, there were fewer physician hand-offs which could subject a patient to erroneous medical decisions.

There have been numerous studies of the risks that occur with patient hand-offs. Each hand-off means a new person is reviewing the medical history, lab results, etc., and errors can occur because the new person fails to recognize a key sign or symptom that is contained in the earlier record or because there are flaws in a hospital’s systems.  

An example is a case we are presently handling. The patient presented to the ER around midnight with severe abdominal pain, and a CT scan was done. It showed intestinal problems that likely needed emergent surgery.  The initial report by the off-site radiologist included a mention of an incidental finding of a kidney mass. The ER doctor then transferred the patient to the surgical service at the hospital, and surgery was done later that day.

In the meantime, the hospital’s radiologist reviewed the film when he came to work that morning, after the patient was admitted for surgery, and noted that the kidney mass was “suspicious for cancer.” That report made it back to the emergency department, whose night shift doctor had ordered the film, but had left for the day after completing his 12-hour shift. The result was that no one picked up on the second radiologist’s opinion, and the patient was never told about the kidney mass. It was finally diagnosed four years later.             

Had the ER doctor been on a longer shift, it is likely he would have received the final report and acted on it by notifying the patient. Of course, the failure to tell the patient also reflected a system error in the hospital’s handling of radiology reports with incidental findings that may be significant.