Intended for healthcare professionals


Why have working hour restrictions apparently not improved patient safety?

BMJ 2011; 342 doi: (Published 22 March 2011) Cite this as: BMJ 2011;342:d1200
  1. Leora I Horwitz, assistant professor, Department of Medicine
  1. 1Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
  1. leora.horwitz{at}

Weak evidence, inadequate regulation, busier doctors, and discontinuity of care are possibilities

Restrictions on hours worked by medical trainees have been in place in the United Kingdom since 1996 and across the United States since 2003. In their systematic review (doi:10.1136/bmj.d1580), Moonesinghe and colleagues concluded that these restrictions have had no negative impact on patient care and medical education; similar results were found in other reviews.1 2 3 It is reassuring that these changes do not seem to have negatively affected education, although we will not know their full impact until several years after these trainees are in independent practice. However, given that one of the fundamental principles behind these reforms was to improve patient safety,4 why have they not benefited patients?

It seems self evident that a reduction in work hours should lead to improvements in patient safety and outcomes. Irrefutable evidence shows that fatigue impairs performance on standardised assessments, both in cognitive and procedural specialties.5 In the real world, however, a simple mandate of working fewer hours may not have improved …

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