63. THE NEXT MORNING: MODIFICATIONS MADE ON ROUNDS TO ORDERS PLACED BY OVERNIGHT ADMITTING RESIDENTS

BackgroundAn increased focus on quality and safety has resulted in increased resident supervision by attending physicians. At our large pediatric academic medical center, the overnight shift is when residents admit general pediatrics patients without immediate attending supervision. As such, admission orders are not evaluated by an attending until morning rounds. To the authors’ knowledge these orders have not been previously evaluated in the academic literature.ObjectivesTo categorize orders placed by residents overnight that were subsequently discontinued on medical rounds the next morning and to examine the reasons for those changes.MethodsWe utilized our hospital's Enterprise Data Warehouse to generate a report of all orders placed on newly admitted patients by residents on the general pediatrics night shift over a 12-month period that were subsequently discontinued the following morning on rounds. All charts were reviewed by two independent reviewers. Orders were categorized by type of order and perceived reason for discontinuation. Disagreements on categorization were discussed with the research team until consensus was achieved.Results290 discontinued patient orders were included in the analysis. Inter-rater agreement was very good with a kappa of 0.91. 66% of orders were medicines, 11% were diets, 4% were diagnostic testing, and 19% were for patient care. Within medication orders, 29% were antibiotics, 17% were antiasthmatics, and 10% were non-narcotic analgesics. The reason for order discontinuation was due to a change in clinical trajectory in 44% of cases (98% of which was patient improvement), primary attending decision in 11% of cases, and due to medical errors in 8% of cases. The most common medical error was a duplicate order (37.5%).ConclusionsThis study suggests that admission orders placed by pediatrics residents overnight are clinically appropriate. Medical errors were most commonly duplicate orders. This pilot identifies the need for further study to better understand the overnight care delivered by residents and to identify areas for increased resident autonomy. An increased focus on quality and safety has resulted in increased resident supervision by attending physicians. At our large pediatric academic medical center, the overnight shift is when residents admit general pediatrics patients without immediate attending supervision. As such, admission orders are not evaluated by an attending until morning rounds. To the authors’ knowledge these orders have not been previously evaluated in the academic literature. To categorize orders placed by residents overnight that were subsequently discontinued on medical rounds the next morning and to examine the reasons for those changes. We utilized our hospital's Enterprise Data Warehouse to generate a report of all orders placed on newly admitted patients by residents on the general pediatrics night shift over a 12-month period that were subsequently discontinued the following morning on rounds. All charts were reviewed by two independent reviewers. Orders were categorized by type of order and perceived reason for discontinuation. Disagreements on categorization were discussed with the research team until consensus was achieved. 290 discontinued patient orders were included in the analysis. Inter-rater agreement was very good with a kappa of 0.91. 66% of orders were medicines, 11% were diets, 4% were diagnostic testing, and 19% were for patient care. Within medication orders, 29% were antibiotics, 17% were antiasthmatics, and 10% were non-narcotic analgesics. The reason for order discontinuation was due to a change in clinical trajectory in 44% of cases (98% of which was patient improvement), primary attending decision in 11% of cases, and due to medical errors in 8% of cases. The most common medical error was a duplicate order (37.5%). This study suggests that admission orders placed by pediatrics residents overnight are clinically appropriate. Medical errors were most commonly duplicate orders. This pilot identifies the need for further study to better understand the overnight care delivered by residents and to identify areas for increased resident autonomy.