Experimental evidence for structured information-sharing networks reducing medical errors.

Errors in clinical decision-making are disturbingly common. Recent studies have found that 10 to 15% of all clinical decisions regarding diagnoses and treatment are inaccurate. Here, we experimentally study the ability of structured information-sharing networks among clinicians to improve clinicians' diagnostic accuracy and treatment decisions. We use a pool of 2,941 practicing clinicians recruited from around the United States to conduct 84 independent group-level trials, ranging across seven different clinical vignettes for topics known to exhibit high rates of diagnostic or treatment error (e.g., acute cardiac events, geriatric care, low back pain, and diabetes-related cardiovascular illness prevention). We compare collective performance in structured information-sharing networks to collective performance in independent control groups, and find that networks significantly reduce clinical errors, and improve treatment recommendations, as compared to control groups of independent clinicians engaged in isolated reflection. Our results show that these improvements are not a result of simple regression to the group mean. Instead, we find that within structured information-sharing networks, the worst clinicians improved significantly while the best clinicians did not decrease in quality. These findings offer implications for the use of social network technologies to reduce errors among clinicians.

Walking the Talk: "Reflexivity" to Advance Integration of Patient Reported Outcomes for Cancer Care Screening.

In this commentary, we propose the use of video-reflexive ethnography (VRE) as a means to support integration of patient-reported outcomes (PROs) in cancer care screening. As for any policy or intervention, the optimization of PROs depends on moving beyond their mere formal introduction, and depends on the integration of PROs in the everyday practice contexts of health care professionals (HPEs). The use of VRE allows for video-playback sessions among oncology professionals to support team-based learning and practice-change grounded in "reflexivity." Through a review of previous methods used to support organizational change in healthcare settings (e.g., policies, quality improvement initiatives, simulation sessions), we present some unsung advantages of VRE that can be applied to a complex integrated setting, such as cancer care. As opposed to other methods to create change, VRE does not dictate new measures, but rather supports "bottom-up" provider-initiated changes to health care practices and contexts, grounded in collaborative day-to-day practice. We argue that VRE optimizes PROs in cancer care by facilitating their effective and sustainable integration, to promote improved patient care.

Editor's Choice - Development and Testing of Step, Error, and Event Frameworks to Evaluate Technical Performance in Peripheral Endovascular Interventions.

OBJECTIVE: Tools for endovascular performance assessment are necessary in competency based education. This study aimed to develop and test a detailed analysis tool to assess steps, errors, and events in peripheral endovascular interventions (PVI). METHODS: A modified Delphi consensus was used to identify steps, errors, and events in iliac-femoral-popliteal endovascular interventions. International experts in vascular surgery, interventional radiology, cardiology, and angiology were identified, based on their scientific track record. In an initial open ended survey round, experts volunteered a comprehensive list of steps, errors, and events. The items were then rated on a five point Likert scale until consensus was reached with a pre-defined threshold (Cronbach's alpha > 0.7) and > 70% expert agreement. An experienced endovascular surgeon applied the finalised frameworks on 10 previously videorecorded elective PVI cases. RESULTS: The expert consensus panel was formed by 28 of 98 invited proceduralists, consisting of three angiologists, seven interventional radiologists, five cardiologists, and 13 vascular surgeons, with 29% from North America and 71% from Europe. The Delphi process was completed after three rounds (Cronbach's alpha; αsteps = 0.79; αerrors = 0.90; αevents = 0.90), with 15, 26, and 18 items included in the final step (73 - 100% agreement), error (73 - 100% agreement), and event (73 - 100% agreement) frameworks, respectively. The median rating time per case was 4.3 hours (interquartile range [IQR] 3.2, 5 hours). A median of 55 steps (IQR 40, 67), 27 errors (IQR 21, 49), and two events (IQR 1, 6) were identified per case. CONCLUSION: An evaluation tool for the procedural steps, errors, and events in iliac-femoral-popliteal endovascular procedures was developed through a modified Delphi consensus and applied to recorded intra-operative data to identify hazardous steps, common errors, and events. Procedural mastery may be promoted by using the frameworks to provide endovascular proceduralists with detailed technical performance feedback.

Telemedicine Could Reduce the Role of Family Physicians to Case Managers.

The COVID-19 pandemic led to the widespread and continuing use of telemedicine in primary care. Despite telemedicine's benefits, it threatens to reduce the role of family physician to that of gatekeeper and case manager, nullifying decades of experience and medical intuition that is more difficult to develop and apply virtually. Additionally, many values of family medicine have eroded during this global process. The narrative presents 3 vignettes that illustrate different ways in which we contend with this complex issue. The challenges presented by telemedicine require us to re-examine our professional and personal values such as maintaining the centrality of the therapeutic relationship with patients. The greatest concern, however, relates to the future of the profession and the ability of new family doctors to overcome the challenges of telemedicine in an increasingly digital world.

Exploring diagnostic events and first referrals in cancer patient pathways in primary care. A questionnaire survey.

BACKGROUND: Cancer diagnostic pathways in general practice are often nonlinear, and several events can delay timely diagnosis. OBJECTIVES: To explore cancer diagnostic processes in general practice, examining how patients' symptom presentations, sex, and age are associated with the occurrence of predefined potentially delaying events and the first referrals. METHOD: General practices in 3 Danish Regions were invited to participate in a questionnaire survey, addressing patient's symptom presentation, diagnostic process events, and first referral. The general practitioners (GPs) received a list of their incident cancer patients from the preceding 2 years. RESULTS: In total 187 general practices participated, including 5,908 patients with the cancer diagnostic pathways initiated in general practice. Presenting with nonspecific symptoms was associated with potentially delaying events, even when the patient also had specific symptoms. Almost half of the patients were referred to a cancer patient pathway (CPP) first, men more often than women, and 10% were referred for acute hospitalization. In 23% of the diagnostic processes, GPs initially treated or referred patients on suspicion of another disease rather than cancer and waited due to normal examinations in 1 out of 20 patients. Excluding sex-specific cancers, these 2 events were more prevalent in women. Men less often complied to the follow-up agreement. Younger patients were less often first referred to a CPP and together with older patients more often first acutely hospitalized. CONCLUSION: In cancer diagnostic processes in general practice, first referrals and the occurrence of potentially delaying events are associated with the patient's age, sex, and specificity of symptoms.

Reducing the risk of NHS disasters.

How could we better use public inquiries to stem the recurrence of healthcare failures? The question seems ever relevant, prompted this time by the inquiry into how former nurse Letby was able to murder newborns under National Health Service care. While criminality, like Letby's, can be readily condemned, other factors like poor leadership and culture seem more often regretted than reformed. I would argue this is where inquiries struggle, in the space between ethics and law-with what is awful but lawful. In response, we should learn from progress with informed consent. Inquiries and civil litigation have seen uninformed 'consent' shift from being undesirable to unlawful. If better leadership and culture were sole drivers here, we would likely be doing far better in many other areas of healthcare too. Instead, one could argue that progress on consent has been made by reducing epistemic injustice-by naming and addressing epistemic issues in ways that enhance social power for patients. If this is an ingredient that transforms clinician-patient working, might it also shift conduct within other key relationships, by showing up what else should become unlawful and why? Naming medical paternalism may have helped with consent reform, so I continue this approach, first naming two areas of epistemic injustice: management feudalism and legal chokeholds Remedies are then considered, including the democratisation of management and reforms to legal ethics, legislation and litigation. In brief, public inquiries may improve if they also target epistemic injustices that should become unlawful. Focus on informed consent and epistemic relationships has improved the medical profession. Likewise, it could help healthcare leaders shift from fiat towards consent, and their lawyers from a stifling professional secrecy towards the kind of candour a prudent public expects.

Getting rights right: implementing 'Martha's Rule'.

The UK government has recently committed to adopting a new policy-dubbed 'Martha's Rule'-which has been characterised as providing patients the right to rapidly access a second clinical opinion in urgent or contested cases. Support for the rule emerged following the death of Martha Mills in 2021, after doctors failed to admit her to intensive care despite concerns raised by her parents. We argue that framing this issue in terms of patient rights is not productive, and should be avoided. Insofar as the ultimate goal of Martha's Rule is the provision of a clinical service that protects patient safety, an approach that focuses on the obligations of the health system-rather than the individual rights of patients-will better serve this goal. We outline an alternative approach that situates rapid clinical review as part of a suite of services aimed at enhancing and protecting patient care. This approach would make greater progress towards addressing the difficult systemic issues that Martha's Rule does not, while also better engaging with the constraints of clinical practice.

Words matter: 'enduring intolerable suffering' and the provider-side peril of Medical Assistance in Dying in Canada.

Enduring intolerable suffering, an essential eligibility criterion in Medical Assistance in Dying (MAiD) in Canada and elsewhere, is a contradiction in terms, in that suffering must be tolerable to be endured. Cases of people who were approved for MAiD but who elected to die naturally, thus tolerating their suffering, bear out the unreliability of this central safeguard. The clinical assessment of intolerable suffering may be strengthened by adopting a definition of intolerable suffering centred on clinically evidenced physical and psychological decompensation. This argument also raises important questions about the risks of MAiD clinicians subjectively defining, approving and providing MAiD in ways that deviate from accepted legal and clinical concepts and ethics. Examples show some prolific clinicians describe MAiD in terminology that differs from such norms, as a personal mission, as personally pleasurable, and as a rights-based service. These alternative views are explored for their risks in assessing and providing MAiD for intolerable suffering. This further demonstrates the need for conceptual clarity in legislation, improved vetting and monitoring of clinicians, and a different assessment process to protect patients and clinicians.

AI and XAI second opinion: the danger of false confirmation in human-AI collaboration.

Can AI substitute a human physician's second opinion? Recently the Journal of Medical Ethics published two contrasting views: Kempt and Nagel advocate for using artificial intelligence (AI) for a second opinion except when its conclusions significantly diverge from the initial physician's while Jongsma and Sand argue for a second human opinion irrespective of AI's concurrence or dissent. The crux of this debate hinges on the prevalence and impact of 'false confirmation'-a scenario where AI erroneously validates an incorrect human decision. These errors seem exceedingly difficult to detect, reminiscent of heuristics akin to confirmation bias. However, this debate has yet to engage with the emergence of explainable AI (XAI), which elaborates on why the AI tool reaches its diagnosis. To progress this debate, we outline a framework for conceptualising decision-making errors in physician-AI collaborations. We then review emerging evidence on the magnitude of false confirmation errors. Our simulations show that they are likely to be pervasive in clinical practice, decreasing diagnostic accuracy to between 5% and 30%. We conclude with a pragmatic approach to employing AI as a second opinion, emphasising the need for physicians to make clinical decisions before consulting AI; employing nudges to increase awareness of false confirmations and critically engaging with XAI explanations. This approach underscores the necessity for a cautious, evidence-based methodology when integrating AI into clinical decision-making.

Global trends and partial forecast of adverse effects of medical treatment from 1990 to 2019: an epidemiological analysis based on the global burden of disease study 2019.

BACKGROUND: The possibility of adverse effects of medical treatment (AEMT) is increasing worldwide, but little is known about AEMT in China. This study analyzed the health burden of AEMT in China in recent years through the Global Burden of Disease Study (GBD) 2019 and compared it with the worldwide average level and those in different sociodemographic index (SDI) regions. METHODS: We calculated the age-standardized rate (ASR) of deaths, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), incidence and prevalence attributed to AEMT in China, worldwide and countries with different sociodemographic indices during 1990-2019 using the latest data and methods from the GBD 2019. RESULTS: From 1990 to 2019, the global age-standardized death rate (ASDR), DALYs, and YLLs for AEMT showed a significant downward trend and were negatively associated with the SDI. By 2040, the ASDR is expected to reach approximately 1.58 (95% UI: 1.33-1.80). From 1990 to 2019, there was no significant change in the global incidence of AEMT. The occurrence of AEMT was related to sex, and the incidence of AEMT was greater among females. In addition, the incidence of AEMT-related injuries and burdens, such as ASR of DALYs, ASR of YLLs and ASR of YLDs, was greater among women than among men. Very old and very young people were more likely to be exposed to AEMT. CONCLUSIONS: From 1990 to 2019, progress was made worldwide in reducing the harm caused by AEMT. However, the incidence and prevalence of AEMT did not change significantly overall during this period. Therefore, the health sector should pay more attention to AEMT and take effective measures to reduce AEMT.

Error traps in patients with congenital heart disease undergoing noncardiac surgery.

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.

Adverse events at the end of life of hospital patients with or without a condition relevant for palliative care: a nationwide retrospective record review study in the Netherlands.

BACKGROUND: Patient safety is crucial for quality of care. Preventable adverse events (AEs) occur in 1 of 20 patients in the hospital, but it is unknown whether this is different for patients with a condition relevant for palliative care. The majority of the limited available research on this topic is only focused on patients already receiving palliative care, and do not make comparisons with other patients at the end-of-life. We identified and compared the prevalence, preventability, nature and causes of AEs in patients with and without a condition relevant for palliative care. METHODS: A nationwide retrospective record review study was performed in 20 Dutch hospitals. A total of 2,998 records of patients who died in hospital in 2019 was included. Records were reviewed for AEs. We identified two subgroups: patients with (n = 2,370) or without (n = 248) a condition relevant for palliative care through the selection method of Etkind (2017). Descriptive analyses were performed to calculate prevalence, nature, causes and prevention strategies. T-tests were performed to calculate differences between subgroups. RESULTS: We found no significant differences between subgroups regarding AE prevalence, this was 15.3% in patients with a condition relevant for palliative care, versus 12.0% in patients without a condition relevant for palliative care (p = 0.148). Potentially preventable AE prevalence was 4.3% versus 4.4% (p = 0.975). Potentially preventable death prevalence in both groups was 3.2% (p = 0.938). There were differences in the nature of AEs: in patients with a condition relevant for palliative care this was mostly related to medication (33.1%), and in patients without a condition relevant for palliative care to surgery (50.8%). In both subgroups in the majority of AEs a patient related cause was identified. For the potentially preventable AEs in both subgroups the two most important prevention strategies as suggested by the medical reviewers were reflection and evaluation and quality assurance. DISCUSSION: Patient safety risks appeared to be equally prevalent in both subgroups. The nature of AEs does differ between subgroups: medication- versus surgery-related, indicating that tailored safety measures are needed. Recommendations for practice are to focus on reflecting on AEs, complemented with case evaluations.

Medication errors in veterinary anesthesia: a literature review.

OBJECTIVE: To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED: PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS: Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Strategies to prevent medical errors by nursing interns: a qualitative content analysis.

BACKGROUND: Nursing interns often face the serious challenges and stress of clinical training. Identifying effective strategies in reducing medical errors can improve student performance and decrease patient risk and injury from errors. The purpose of this study was to identify strategies to prevent medical errors by nursing interns in Medical Universities in Sistan and Baluchistan, Southeast of Iran. METHODS: This is a qualitative study using a content analysis approach. Purposive sampling was used. The study was conducted in 3 medical universities. Ten nursing interns participated in this study. Open-ended, semi-structured, and face-to-face, interviews were used to explore the experience of nursing interns about strategies to prevent medical errors during their internship. RESULTS: Findings include 20 subcategories, 6 categories and one theme. The main theme is "strategies to prevent medical errors during internship". Six categories included "strategies to prevent medical errors during internship". These included "Professional acceptance and support", "Revision of the implementation of the educational curriculum", "Retraining courses for challenging skills", "Creating learning opportunities" "Professionalization", and "Facilities and requirements". CONCLUSIONS: Preventing medical errors requires different strategies before and during nursing internship. Error prevention strategies include retraining and preparatory courses for challenging areas, evaluation of students' performance, and accepting students as members of the health care team, respecting and supporting them and protecting their rights. Learning from medical errors, analysis and reflection on errors should be part of the curriculum during the internship.

Nurses' experiences of reporting the medical errors of their colleagues: a qualitative study.

BACKGROUND: Medical error is a leading cause of disability and death in healthcare settings and reporting colleagues' medical errors is one of the main strategies for medical error management and an ethical responsibility of all healthcare providers, including nurses. Most studies into reporting colleagues' medical errors used quantitative designs while it seems that using qualitative designs can provide better insight in this area. PURPOSE: This study explored nurses' experiences of reporting the medical errors of their colleagues. METHODS: This qualitative study was conducted using the conventional content analysis approach. Participants were 22 hospital nurses purposively selected in 2021-2022 from different cities in Iran. Twenty-two in-depth semi-structured interviews were held for data collection. The data were analyzed via Graneheim and Lundman's conventional content analysis and trustworthiness was maintained using the criteria proposed by Guba and Lincoln. FINDINGS: The main categories of the study were burnout and intention to leave the profession and growth and development. The two subcategories of the first category were the experience of injury and the experience of violence and the two subcategories of the second category were sense of worthiness and sense of motivation. Moral distress was the most important experience of almost all participants. CONCLUSION: Nurses mostly have negative experiences in terms of reporting their colleagues' medical errors. Negative experiences can act as the barriers to report colleagues' errors while positive experiences can act as its facilitators. Improvement of the patient safety culture in healthcare settings and interpersonal relationships among healthcare providers can reduce the negative experiences and promote the positive experiences of reporting colleagues' medical errors.

The Challenges of Implementing a Safety Culture.

This article provides an update on patient safety data recently reviewed by and recommendations of the President's Council of Advisors on Science and Tech - nology. This article attempts to capture the impact of the eroding ability of the nursing workforce to perform its traditional role of blocking errors before they harm patients. Some strategies, tactics, and practice examples to assist in renewing this protective capacity in today's challenging environment are presented. Finally, acknowledging the variability of substantive support for maintaining a safety culture provided by individual health care organizations, this article encourages and applauds the personal courage of nephrology nurses and other health care providers as they engage and assist their clinical and quality improvement teams in addressing the persistence of what Hughes (2008) termed the "everydayness of errors" (p. 1-7).

Increasing the margin of patient safety for periodontal and implant treatments: The role of human factors.

Early complications following periodontal and dental implant surgeries are typically attributed to technique or poor biological response, ignoring the possibility of the human element. Interestingly, significant experience is not correlated with increased success, whereas evidence supports the impact of clinical behavior on patient outcome. This is the result of errors, much like those scrutinized in other high-risk technical fields, such as aviation. What can be surprising is that those who make these errors are very well acquainted with best practices. Given this, how is it possible for the conscientious practitioner to fail to apply protocols that are nonetheless very well known? Recently, the concepts of human and organizational factors have been translated to medicine, though dentistry has been slow to recognize their potential benefit. This review lists specific human factor behaviors, such as use of checklists and crew resource management, which might improve postsurgical outcome.

Patient safety classifications, taxonomies and ontologies, part 2: A systematic review on content coverage.

BACKGROUND: Content coverage of patient safety ontology and classification systems should be evaluated to provide a guide for users to select appropriate ones for specific applications. In this review, we identified and compare content coverage of patient safety classifications and ontologies. METHODS: We searched different databases and ontology/classification repositories to identify these classifications and ontologies. We included patient safety-related taxonomies, ontologies, classifications, and terminologies. We identified and extracted different concepts covered by these systems and mapped these concepts to international classification for patient safety (ICPS) and finally compared the content of these systems. RESULTS: Finally, 89 papers (77 classifications or ontologies) were analyzed. Thirteen classifications have been developed to cover all medical domains. Among specific domain systems, most systems cover medication (16), surgery (8), medical devices (3), general practice (3), and primary care (3). The most common patient safety-related concepts covered in these systems include incident types (41), contributing factors/hazards (31), patient outcomes (29), degree of harm (25), and action (18). However, stage/phase (6), incident characteristics (5), detection (5), people involved (5), organizational outcomes (4), error type (4), and care setting (3) are some of the less covered concepts in these classifications/ontologies. CONCLUSION: Among general systems, ICPS, World Health Organization's Adverse Reaction Terminology (WHO-ART), and Ontology of Adverse Events (OAE) cover most patient safety concepts and can be used as a gold standard for all medical domains. As a result, reporting systems could make use of these broad classifications, but the majority of their covered concepts are related to patient outcomes, with the exception of ICPS, which covers other patient safety concepts. However, the ICPS does not cover specialized domain concepts. For specific medical domains, MedDRA, NCC MERP, OPAE, ADRO, PPST, OCCME, TRTE, TSAHI, and PSIC-PC provide the broadest coverage of concepts. Many of the patient safety classifications and ontologies are not formally registered or available as formal classification/ontology in ontology repositories such as BioPortal. This study may be used as a guide for choosing appropriate classifications for various applications or expanding less developed patient safety classifications/ontologies. Furthermore, the same concepts are not represented by the same terms; therefore, the current study could be used to guide a harmonization process for existing or future patient safety classifications/ontologies.

The misplaced embryo: legal parenthood in 'embryo mix-up' cases.

Recently in Israel, a woman was mistakenly implanted with an embryo that is genetically related to another couple. Unfortunately, this case is not an isolated occurrence, as other cases of embryo mix-ups have been reported in several countries, including the USA, China, the UK and various other countries within the European Union. Cases of mixed-up embryos are ethically and legally complex: the woman who carried the pregnancy and the woman who is genetically related to the resulting child-both of whom endured emotionally and physically demanding infertility treatments-along with their partners, may be unwilling to relinquish parental rights over the child.This article explores four possible approaches, found in numerous common law jurisdictions, which can be used to address cases involving embryo mix-ups. Our analysis reveals several avenues through which legal parentage can be established. It can be done through gestation and the marital presumption, genetic connections, by adhering to the principle of the best interests of the child, or by recognising multiple individuals as legal parents. We review the advantages and disadvantages of each approach, but we have one clear recommendation: resolving embryo mix-up cases should be done proactively through the establishment of legislation and guidelines, rather than relying on post hoc individual court decisions. Such legislation and guidelines should guarantee the consistency of values throughout diverse reproductive contexts and mandate that fertility clinics and medical professionals provide individuals with comprehensive information regarding the potential risks associated with assisted reproductive treatments.

"Multivariate analysis of the impact of sleep and working hours on medical errors: a MICE approach".

BACKGROUND: The main objective of this study was to describe the relationship between working conditions, sleep and psycho-affective variables and medical errors. METHODS: This was an observational, analytical and cross-sectional study in which 661 medical residents answered questionnaires about working conditions, sleep and psycho-affective variables. Actigraphic sleep parameters and peripheral temperature circadian rhythm were measured in a subgroup of 38 subjects. Bivariate and multivariate predictors of medical errors were assessed. RESULTS: Medical residents reported working 66.2 ± 21.9 weekly hours. The longest continuous shift was of 28.4 ± 10.9 h. They reported sleeping 6.1 ± 1.6 h per day, with a sleep debt of 94 ± 129 min in workdays. A high percentage of them reported symptoms related to psycho-affective disorders. The longest continuous shift duration (OR = 1.03 [95% CI, 1.00-1.05], p = 0.01), working more than six monthly on-call shifts (OR = 1.87 [95% CI, 1.16-3.02], p = 0.01) and sleeping less than six hours per working day (OR = 1.66 [95% CI, 1.10-2.51], p = 0.02) were independently associated with self-reported medical errors. The report of medical errors was associated with an increase in the percentage of diurnal sleep (2.2% [95% CI, 0.1-4.3] vs 14.5% [95% CI, 5.9-23.0]; p = 0.01) in the actigraphic recording. CONCLUSIONS: Medical residents have a high working hour load that affect their sleep opportunities, circadian rhythms and psycho-affective health, which are also related to the report of medical errors. These results highlight the importance of implementing multidimensional strategies to improve medical trainees' sleep and wellbeing, increasing in turn their own and patients' safety.