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Patient Safety Tip of the Week

December 15, 2020

Our Perennial Pre-Holiday Warning: “Be Careful Out There!”



Since this is our last column prior to the holidays, it’s time for our annual warning: “Be careful out there!”. Be very wary about patient safety vulnerabilities during the holidays. We don’t have statistics to verify that medical errors and incidents are more frequent around the holidays. But anecdotes abound. We have had two dear friends suffer serious incidents while inpatients on Christmas Day. In each case there was lack of attention to critical events during evolving clinical situations, likely due to coverage issues or other distractions related to the holiday. In one case, lack of consultant availability led to lack of appropriate intervention in a patient with colonic pseudo-obstruction (Ogilvie’s syndrome) after an orthopedic procedure. That patient developed sepsis and died. In the other case, a several hour period of inattention to serum electrolytes led to rapid overcorrection of hyponatremia and consequent osmotic demyelination syndrome.


Staffing issues, coverage issues, and distractions are more common on holidays and are potential factors contributing to incidents. And it’s not just the day of the holiday that is important. Sometimes the time pressures created by a holiday may be contributing factors to incidents on the following day(s). In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we speculated about the impact of such time pressures contributing to the patient being sent for a PET scan late in the day, during which a fatal mistake took place.


There has been at least one study that looked systematically at mortality related to public holidays. Smith et al. (Smith 2014) found that adjusted public holiday mortality in the all public holidays versus all other days analysis was 48% higher at 7 days (OR 1.48) and 27% higher at 30 days (OR 1.27). Interactions between the weekend variable and the public holiday variable were not statistically significant. They concluded that patients admitted as emergencies to medicine on public holidays had significantly higher mortality at 7 and 30 days compared with patients admitted on other days of the week.


We have, of course, done multiple columns on the “weekend effect” and the impact of time of day or “after hours” care (see columns listed below). And we’ve described a host of factors that are different in hospitals on weekends, evenings and nights, and holidays compared to daytime.


But one factor that hasn’t received very much attention is the impact of distractions during those periods of vulnerability. To try to focus on that factor among so many others, Kato and colleagues (Kato 2020) recently took an innovative approach – they looked at mortality for patients operated on by surgeons on the surgeons’ birthdays! They looked at mortality in Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures. Of almost a million cases, 0.2% were performed by surgeons on the surgeons’ birthday.


The overall unadjusted 30-day mortality on the operating surgeon’s birthday was 7.0% and that on other days was 5.6%. After adjustment for patient characteristics and other potential confounders, patients who underwent surgery on a surgeon’s birthday exhibited higher mortality compared with patients who underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; P=0.03). They interpreted these findings as suggesting that surgeons might be distracted by life events that are not directly related to work. They note that, while that hypothesis is intuitive, it has been otherwise difficult to assess, owing to lack of detailed information on events that are potentially distracting to an individual surgeon.


The authors go on to discuss several potential mechanisms that might explain these findings. First, and foremost, are the time pressures that might be operative on a surgeon’s birthday (eg. need to be at a scheduled family event). But other distractions could be related to simple things like conversations with other OR staff about birthdays or receiving text/phone messages with birthday wishes. They speculate that perhaps surgeons are more likely to delegate parts of the procedures to residents and fellows, and that perhaps post-operative care decisions might be impacted (as an example, they speculate a surgeon might be less likely to return to the hospital to see their patients who show signs of deterioration if they are having dinner with family and friends, compared with regular evenings).


We were originally going to title this column “OMG! Don’t Tell Me Your Stats. Tell Me Your Date of Birth!” Is it more important to ask your surgeon about his/her birthday than his/her surgical outcome statistics? And what about his/her anniversary or his/her children’s birthdays? Or his/her tee time? Those questions are, of course, absurd. But it does remind us that certain life events may make us more vulnerable to distractions and subsequent errors. Perhaps we need to be more careful in on-call scheduling to avoid being put in vulnerable positions on such days. But, most of all, we need to recognize that certain occasions and events increase the possibility we will be distracted and take special care on those days to avoid those distractions.


The Kato study makes a very important point that we are all more vulnerable to distraction at certain times. But we don’t want to take away from our focus on reminding everyone of the need for extra vigilance and care during the holidays.


Happy holidays to all! Stay safe and practice safely!



Some of our previous columns on the “weekend effect:

·       February 26, 2008     Nightmares….The Hospital at Night

·       December 15, 2009   The Weekend Effect

·       July 20, 2010             More on the Weekend Effect/After-Hours Effect

·       October 2008            Hospital at Night Project

·       September 2009        After-Hours Surgery – Is There a Downside?

·       December 21, 2010   More Bad News About Off-Hours Care

·       June 2011                  Another Study on Dangers of Weekend Admissions

·       September 2011        Add COPD to Perilous Weekends

·       August 2012              More on the Weekend Effect

·       June 2013                  Oh No! Not Fridays Too!

·       November 2013        The Weekend Effect: Not One Simple Answer

·       August 2014              The Weekend Effect in Pediatric Surgery

·       October 2014            What Time of Day Do You Want Your Surgery?

·       December 2014         Another Procedure to Avoid Late in the Day or on Weekends

·       January 2015             Emergency Surgery Also Very Costly

·       May 2015                  HAC’s and the Weekend Effect

·       August 2015              More Stats on the Weekend Effect

·       September 2015        Surgery Previous Night Does Not Impact Attending Surgeon Next Day

·       February 23, 2016     Weekend Effect Solutions?

·       June 2016                  Weekend Effect Challenged

·       October 4, 2016        More on After-Hours Surgery

·       July 25, 2017             Can We Influence the “Weekend Effect”?

·       August 15, 2017        Delayed Emergency Surgery and Mortality Risk

·       September 2020        Care Processes and the Weekend Effect

·       October 13, 2020      Night-Time Surgery


Some of our previous columns on “after-hours” surgery:

·       September 2009        After-Hours Surgery – Is There a Downside?

·       October 2014            What Time of Day Do You Want Your Surgery?

·       January 2015             Emergency Surgery Also Very Costly

·       September 2015        Surgery Previous Night Does Not Impact Attending Surgeon Next Day

·       October 4, 2016        More on After-Hours Surgery

·       August 15, 2017        Delayed Emergency Surgery and Mortality Risk

·       October 24, 2017      Neurosurgery and Time of Day

·       December 2019         Surgeon On-Call Shifts

·       October 13, 2020      Night-Time Surgery






Smith S, Allan A, Greenlaw N, Finlay S, Isles C. Emergency medical admissions, deaths at weekends and the public holiday effect. Cohort study. Emerg Med J 2014; 31: 30-34



Kato H, Jena AB, Tsugawa Yusuke T. Patient mortality after surgery on the surgeon’s birthday: observational study BMJ 2020; 371: m4381





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