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Perspective |
1 Department of Radiology, Rush North Shore Medical Center and Rush Medical College, 9600 Gross Point Rd., Skokie, IL 60076.
Received October 16, 2007; accepted after revision October 17, 2007.
Address correspondence to L. Berlin
(lberlin{at}rsh.net).
Keywords: liability of medical centers • malpractice • residents' working hours
On July 14, 1997, after completing her 36-hour work shift at a large academic medical center in Chicago, a first-year internal medicine resident got into her automobile to drive home. En route, the resident fell asleep behind the wheel of her car and struck a car driven by a 23-year-old woman. The woman sustained a head injury that left her permanently disabled.
The injured woman (plaintiff) filed a medical malpractice lawsuit against the medical center alleging that the center "knew or should have known that the resident had worked 34 of the 36 hours she had been on duty and that it knew or should have known that the resident therefore was tired from the excessive hours she worked and left the hospital with impaired judgment because she was deprived of sleep." The plaintiff maintained that the medical center had been negligent by breaching a duty it had "to prevent the injury caused by the resident's condition" [1, 2]. The trial court judge dismissed the lawsuit on the basis that the medical center owed no legal duty to the plaintiff. The plaintiff then appealed the trial court's dismissal to the Illinois Appellate Court.
The Appellate Court Decision
The appellate court acknowledged that data show that "hospitals know, or reasonably should know, that there is a high percentage of residents who fall asleep behind the wheel of a car after leaving work." Nonetheless, the court upheld the lower court's dismissal of the lawsuit [2]:
Plaintiff maintains it is reasonably foreseeable and likely that drivers who are sleep deprived will cause traffic accidents resulting in injuries. Plaintiff also maintains that such injuries could be prevented if hospitals either changed work schedules of their residents or provided them with additional rest periods.... But, there is no liability imputed to health care providers for injuries to nonpatient third parties.
Medical Legal Issues
Clearly, a hospital or medical center that pays the salary of residents assumes the legal liability for negligent conduct committed by those residents if the conduct is related to the residents' duties [3]. However, a hospital is not liable for negligent conduct committed by employed residents if that conduct is not related to the duties of the resident while working outside the hospital [4]. The issue presented in the lawsuit discussed here is unique, however, because the alleged act of negligence did not fall neatly into either one of these scenarios. Although at the time she caused the automobile accident the resident was neither on duty nor carrying out duties required by the residency, she was admittedly physically and mentally impaired because of work requirements that were imposed by the hospital when she had been on duty.
The Illinois Appeals Court declined to hold the medical center liable or impose on it a legal duty to avoid injury to a third party even though the medical center was apparently responsible for the resident's sleep-deprived condition when she caused the accident. Appeals courts in other states, however, have ruled differently on this issue. Although not specifically dealing with health care entities or patients, the legal issue presented in the following four cases—whether a business or other entity that has imposed on its employees working conditions that can cause the employees to remain physically or mentally impaired after going off duty, which in turn causes an injury to a third-party individual, can be held liable for that third party's injury—was very similar to that ruled on by the Illinois court. These cases are thus worthy of brief review.
Employers' Liability for Work-Imposed Impairment of Their Employees
After reporting to work at 7:00 am, a 19-year-old West Virginia railroad employee was asked to work removing debris from and repairing a track that had been damaged by a derailment. The work consisted of heavy manual labor that included lifting railroad ties and shoveling coal. It continued long past the 19-year-old's normal 3:30 pm quitting time. At 10:00 pm, while still working, the 19-year-old told his foreman he was tired and wanted to go home, but he was asked to continue working. At 1:00 am, the worker was given a few minutes to eat and again he asked his foreman if he could go home. Again, he was told to go back to work. Finally, just before 10:00 am, nearly 27 hours after he had begun working, the young man was told he could leave for home. The 19-year-old got into his car and began the trip home, but en route, he fell asleep. A witness later testified that the automobile driven by the young man was traveling at about 70 miles per hour and crashed into a car traveling in the same direction. The driver of the rear-ended car sustained permanent disabling injuries.
The injured driver later filed a lawsuit against the railroad, claiming that the railroad "illegally, willfully, wantonly, negligently, and with a conscious disregard for the rights and safety of others," required its 19-year-old employee to work more than 27 hours straight "without providing rest or transportation home when it knew or should have known that its employee constituted a menace to the health and safety of the public." The trial court dismissed the lawsuit, ruling that the railroad owed no duty of care to the third-party driver who had been injured as a result of the negligent act of the railroad worker. The case was then appealed to the West Virginia Supreme Court, which reversed the lower court's dismissal [5]:
We recognize that under traditional principles, an employer is normally under no duty to control the conduct of an employee acting outside the scope of his employment. The issue presented here, however, is not the railroad's failure to control the employee while driving on the highway; rather it is whether the railroad's conduct before the accident created a foreseeable risk of harm.... The issue raised is whether the railroad's conduct in requiring its employee to work over 27 hours and then setting him loose on the highway without providing alternate transportation to its exhausted employee created an unreasonable risk of harm to others. We believe the railroad could have reasonably foreseen that its exhausted employee would pose a risk of harm to other motorists while driving home.We conclude that the trial court erred in ruling that the railroad owed no duty to the injured driver. We are unable to say that the railroad's conduct did not create a foreseeable risk of harm to others which the railroad had a duty to guard against...or that the railroad's negligence did not reduce the capability of its employee to think and act as a reasonable person.
The same legal issue, although again not involving health care facilities or patients, was adjudicated by a California Appellate Court. In that case, an employer hired a pest control company to spray pesticide overnight to eliminate fleas in its facility. At 7:00 am the next day, a clerical employee arrived for work. By 10:00 am, the employee felt ill with complaints of headache, nausea, and tightness in her chest, all of which appeared to be related to the fumes and effects of the pesticide. Feeling no better by 12 noon, the employee asked her supervisor if she could go home. The supervisor asked whether the employee was well enough to drive home. After receiving an affirmative answer, the supervisor permitted the employee to leave. On the way home, the employee rear-ended a woman whose automobile had been stopped at a red light, causing severe injuries. Police officers who arrived at the scene of the accident reported that the employee complained of having felt dizzy and light-headed just before the accident.
The injured driver later filed a lawsuit against the clerical employee's employer, alleging that the employer was responsible for the negligent conduct of the employee inasmuch as the employee was acting within the course and scope of her employment when she was driving home, ill from pesticide exposure. The employer's defense attorney moved for dismissal, arguing that a "going–and–coming" rule meant that the employee was not acting within the course and scope of employment during her commute to and from home. Accordingly, argued the defense attorney, the employer should not be held vicariously liable for the employee. The trial court dismissed the case, which was then appealed to the California Appellate Court. That court reversed, stating [6]:
Case law has established the general rule that an employee is outside the scope of his employment while engaged in his ordinary commute to and from his place of work. This principal is known as the "going–and–coming" rule.... This rule is not ironclad, however. One exception applies when an employee endangers others with a risk arising from or related to work.... Liability is properly applied where an employee undertakes activities within his or her scope of employment that caused the employee to become an instrumentality of danger to others even when the danger may manifest itself at times and locations remote from the ordinary workplace.The employee suffered pesticide exposure at work to which she attributed illness and impaired driving. The employee was an "instrumentality of danger" because of what had happened to her at work.
An Oregon Appellate Court focused on the same legal issue, again not involving health care facilities or personnel. In that case, a high school student who worked part-time in the evening at a McDonald's restaurant was asked to work beyond the restaurant's 11:00 pm closing time to perform various cleanup duties. His work continued until the following morning, when he told the restaurant's manager that he was tired and asked to be excused to go home. The manager agreed. The student began his automobile trip home, but a short time later became drowsy and fell asleep. At the bend in the road, his car crossed the dividing line into the lane of oncoming traffic and crashed into a van. The student was killed, and the driver of the van was severely injured.
After the injured driver settled his potential claim against the dead student's family, he then filed a lawsuit against McDonald's, alleging that the restaurant was negligent in requiring the student to work too many hours without adequate rest and then permitting the student to drive a car when the restaurant should have known that the student could not drive safely. The lawsuit was tried, and the jury returned a verdict in favor of the plaintiff. The restaurant appealed seeking reversal, but the Oregon Appellate Court affirmed the decision [7]:
The restaurant controlled all work assignments. Therefore, the restaurant knew or had reason to know of the number of hours the student had been working and that working the student so many hours would impair his ability to drive home safely.... The restaurant's supervisor saw the student in a visibly fatigued state and continued to work him as scheduled. In that regard, the supervisor was much like a bartender who served alcoholic beverages to a visibly intoxicated person and then caused an automobile accident that harmed another.... Because the bartender saw the driver in a visibly intoxicated state and it is reasonably foreseeable that the customer will drive when he or she leaves, the bartender is liable for the consequences of the automobile accident.... The jury verdict is affirmed.
Although the Oregon Appellate Court's majority opinion is the official one, it is of interest to note the strong dissent of one of the appellate justices [7]:
The majority's decision is without precedent in Oregon. It makes all employers potentially liable for their employees' off-premises negligence when an employee becomes tired as a result of working.... No rule of negligence requires an employer to inquire into the private lives of its adult employees to determine if, on a given occasion, the employee is not getting enough sleep. The student volunteered to work the cleanup shift. There is no evidence that he was pressured in any way to work the shift.... The student was not on the restaurant's business premises and was on his own time when he drove home from working that morning. He was not acting on the restaurant's behalf, nor did the restaurant have actual control of or the right to control the student's driving conduct. Moreover, the restaurant personnel did not prevent the student from choosing to have someone pick him up after work or to take a nap in his car before driving home or some other preventive measure.The majority's analysis is wrong.... The proprietors of fast food restaurants in Oregon will be surprised to learn that scheduling an employee to work an extra shift carries with it the same legal consequences as the inherent hazard of serving alcoholic beverages to an intoxicated patron. The majority's holding makes employers, in their scheduling decisions, responsible for anticipating what their employees' off-premises activities will be after work: a responsibility of enormous implications and proportions.... In effect, the opinion says to Oregon employers, "Do not schedule your employees in a manner that will cause fatigue because if you do, you risk liability for negligence in the event that your employee acts in a negligent manner off-premises and after work."
In yet another case involving the same legal issue but with a somewhat different set of facts, the Texas Supreme Court ruled in similar fashion. There, a nightclub instructed its waitresses to take specific steps to increase the number of alcoholic drinks that customers bought for dancers. Waitresses were instructed to ask customers if they would like to get a dancer for their table because "customers will buy drinks for dancers and buy dances from them, resulting in a larger tab." The dancers were told that if they wanted to keep their jobs, they had to drink along with the customer. One particular dancer consumed at least 12 alcoholic beverages with customers and became intoxicated. While driving herself home after performing her last table dance at 1:00 am, the dancer's car struck a guardrail and she suffered serious personal injuries. The dancer later sued the night-club under the Texas Alcoholic Beverage Code, commonly called the Dram Shop Act. The nightclub's attorneys sought dismissal, arguing that "The imbiber maintains the ultimate power and thus the obligation to control his own behavior: to decide to drink or not to drink, to drive or not to drive" [8]. Attorneys for the dancer countered that because the nightclub required its workers to consume alcohol, a duty should be imposed on it to prevent the dancer from driving while in an impaired condition. The case reached the Texas Supreme Court, which ruled that the employer did indeed have such a duty [8]:
Work-related intoxication is a hazard of the employment that follows an employee when he or she leaves work. When an employer encourages or condones excessive drinking on the job, the employer ought to be held responsible for foreseeable injuries suffered by the employee because of the resulting intoxication.... The employer cannot turn a blind eye when that same employee gets into her vehicle and drives home intoxicated, jeopardizing her life and the lives of other motorists.... The employer must take reasonable steps to prevent foreseeable injury caused by drunk driving.
Notwithstanding that of the court decisions just cited only the Illinois case involved a health care facility and health care worker, all are characterized by the same common-denominator legal issue: whether an employer has a duty to take steps to prevent an employee who it has reason to believe is mentally or physically impaired as a result of working conditions imposed by the employer from driving an automobile after leaving work. Although an Illinois court declined to impose such a duty, the other courts mentioned here did—notwithstanding a dissenting opinion from an Oregon judge. Will future courts rule differently on the question of whether an employer is liable for negligent acts of an off-duty medical resident employee, overworked and sleep deprived because of work requirements, than for similar negligent acts of an off-duty overworked sleep-deprived railroad or restaurant employee, an employee who became ill because of the inhalation of noxious fumes in the place of employment, or an exotic dancer intoxicated by alcohol consumption that was required as part of the job description? The answer is yet to be determined.
Although involving an allegedly overworked on-duty attending physician rather than an off-duty, sleep-deprived resident, a recently filed lawsuit in Pennsylvania deals with the same legal issue, albeit from a slightly different perspective [9]. A pregnant woman and her husband sued a hospital alleging that it maintained "a health care practice with an unmanageable number of patients," causing an obstetrician–gynecologist to be overworked to the extent that his treatment of the woman was negligent. The obstetrician had noted fewer fetal movements during an examination when the woman was 37 weeks pregnant, but instead of admitting the woman, he discharged her. A week later, the woman delivered a stillbirth. The obstetrician testified during his deposition that the hospital forced him to see an extremely high number of patients each day and that he had approached hospital administrators with concerns about the workload, but none was ever addressed. The lawsuit is still pending as this article is being written.
Sleep-Deprived Residents and Motor Vehicle Accidents
Let us return to the Illinois case discussed at the beginning of this article, now focusing our attention not on the legal question of liability of the medical center but rather on the relationship between sleep-deprived residents and motor vehicle accidents. Much has been written on this subject.
A 1995 British survey of all vehicle accidents occurring in Southwest England revealed that 16% were caused by drivers who had fallen asleep while driving [10]. Focusing on the "perils of drowsy driving," a 1997 New England Journal of Medicine editorial likened drowsy driving to drunk driving. It pointed out that sustained wakefulness for 17 hours decreased an individual's performance to the same degree as a blood alcohol concentration of 0.05%, which is the legal limit for driving in France, The Netherlands, Norway, and Finland [11]. In most of the United States, the legal definition of impairment due to alcohol consumption is a blood alcohol concentration of 0.08%, which is generally considered to be produced by approximately three 45-mL (l.5 oz) drinks of spirits. This would appear to correspond to a 27-hour period of sustained wakefulness.
"Sleepiness" and "fatigue" are often used interchangeably, but they are not exactly synonymous [12]. Fatigue is defined as "the subjective state in which one can no longer perform a task effectively." Sleepiness is more specific, defined as "reduced alertness as a result of increased pressure to fall asleep." Interviews of automobile drivers in New York revealed that 55% admitted to having driven while sleepy and 23% had actually fallen asleep while driving at some time in their lifetime; 5% had experienced a crash due to falling asleep while driving [12]. There is evidence that young adults experience greater levels of sleepiness than older people with similar levels of sleep loss [13].
Several studies focusing on motor vehicle crashes among residents and interns have been published. A survey of radiology residents revealed that 47% admitted to brief periods of sleep when they weren't aware of dozing off, and 30% reported that they had actually fallen asleep while driving when they were on call [14]. Surveying motor vehicle crashes and near-miss incidents among more than 2,700 residents, Harvard University researchers found that the odds that residents will have a documented motor vehicle crash during the commute after an extended work shift exceeding 24 consecutive hours were more than double the odds than after a nonextended shift [15]. Near-miss incidents were more than five times as likely to occur after a greater than 24-hour work shift than they were after a nonextended shift. Other researchers reported that anesthesiology residents working their normal schedules had a significant degree of daytime sleepiness approaching the level seen in patients with narcolepsy or sleep apnea [16].
To assist house staff physicians in managing their sleep so that they minimize risk to themselves and their patients when working nightshifts, the United Kingdom's Royal College of Physicians prepared a guide titled "Working the Nightshift: Preparation, Survival and Recovery" [17]. The manual includes many helpful suggestions such as "Take a 2-hour afternoon sleep before coming on duty," "Take 20- to 45-minute naps to counteract fatigue," and "Do not miss proper meals when working at night."
It is obvious that one way to curtail sleepiness among drivers is to reduce the drivers' working hours before their driving. The U.S. Department of Transportation restricts the duty hours of commercial truck drivers [12]. In a similar vein, the Accreditation Council on Graduate Medical Education (ACGME) has done the same with regard to working hours of residents. The ACGME restriction was not instigated because of the frequency of automobile crashes, however. Rather, it was instigated by an event that virtually revolutionized modern medical education: the death of a young woman by the name of Libby Zion.
The Libby Zion Case
On the evening of October 4, 1984, Libby Zion, an 18-year-old college freshman, was admitted to a New York hospital at 12 midnight with fever and what appeared to be minor flu symptoms [18, 19]. The young woman had previously undergone psychiatric treatment for stress and had been treated at various times with drugs such as phenelzine, oxycodone with aspirin, flurazepam, diazepam, and a number of antibiotics [20]. She also had had a history of cocaine ingestion [21]. On the hospital ward to which she was admitted, Libby was evaluated by two residents, one just 8 months out of medical school, the other with 1 year of additional training. The events that occurred over the next few hours will always remain controversial, but what is indisputable is that within 9 hours after admission, Libby suffered a cardiac arrest and died.
Libby's father, Sidney Zion, a well-known New York journalist and former federal prosecutor, became convinced that his daughter's death was caused by inadequate staffing and supervision of house staff at the hospital. With considerable coverage by the news media, Zion began characterizing Libby's death as "murder" [18]. He discovered that one resident caring for his daughter had been working a 36-hour shift and that another resident who was supposed to be involved in her care had never been awakened when Libby's physical condition began to deteriorate. Although a later investigation determined that the many mistakes made in the clinical care of Libby Zion were due to poor judgment rather than to sleep deprivation of the residents, Sidney Zion focused his attention solely on the resident's long 36-hour shift and "vented his outrage about the state of medical education widely and loudly" [18]. A grand jury that was later convened to investigate Libby Zion's death did not find cause for criminal indictment of the physicians, but it did indict the way medical residents were trained at New York hospitals and elsewhere. The New York State Health Department subsequently fined the New York hospital $13 million and eventually passed the "Libby Zion Law," by which New York State regulated the working hours of hospital residents, limiting work to 80 hours per week and no more than 24 consecutive hours on duty.
Sidney Zion also filed a medical malpractice lawsuit against the hospital and residents. In 1995, after nearly a decade of repeated court-room delays and 11 years after Libby Zion's death, the malpractice trial ended with a jury awarding the Zion family $750,000. The judge later reduced the award to $375,000.
At first the Libby Zion reforms covered only hospitals in New York, and many physicians and institutions essentially disregarded the new regulations [18]. "One simply could not become a qualified doctor without experiencing firsthand what happens during the often unpredictable first 36 hours of a patient's illness," commented one outspoken physician critic. In 2003, however, the Libby Zion case played a major role in instituting reforms in graduate medical education that changed the landscape regarding residents' work hours throughout the nation.
ACGME Standards Limiting Residents' Duty Hours: Perceptions and Compliance
Sleep deprivation due to extended work hours and circadian disruption has long been a concern and, in fact, has been called the "Achilles' heel" of the medical profession [22]. In response to a growing body of scientific data about the negative effects of sleep loss and fatigue on resident education and performance [23, 24], not the least of which was generated by the aftermath of the public uproar over the Libby Zion case, the ACGME in July 2003 instituted standards that limit duty hours for resident physicians in all accredited programs [22]. The standards called for an 80-hour weekly limit, 10 hours of rest between duty periods, a 24-hour limit on continuous duty, 1 day in 7 free from patient care and educational obligations, and in-house call duty of no more than once every 3 nights [25].
The ACGME action limiting resident work hours has not been without its critics. Some researchers have claimed that the cause of most medical errors and adverse events has never been and still is not fatigued, overworked residents but rather myriad other explanations: "A fatigued resident is but one small cog in the wheel of medical care" [26]. On the other hand, many studies have confirmed the strong association between residents' work hours and medical errors. Interns rotating in intensive care units have been shown to commit substantially more serious medical errors when they worked shifts of 24 hours or more than when they worked shorter shifts [27]. David C. Leach, executive director of the ACGME, has stated that as a result of resident work-hour limitations, patients are safer and that residents are better trained [28]. His opinion is supported by Harvard University researchers who found that first-year medi cal school graduates working five shifts of 24 hours or more during a month were three times more likely to make an error that contributed to a patient's death than those working fewer hours [29]. In a study evaluating the relationship between hospital mortality and residency work-hour limitations in more than 1.2 million patients, Stanford University researchers found that ACGME regulations were associated with a reduction in the absolute mortality rate [30, 31]. Other researchers have also found improved outcomes in patients as a result of ACGME limitations [32, 33].
Still other researchers, however, have found that ACGME duty hour reforms have not been associated with improvement in mortality of patients [34]. Despite various studies showing improvement in mortality in subgroups of patients, the overall impression remains that duty hour restrictions have had little effect on patient mortality [35]. In addition, some studies have shown that limiting work hours diminishes the educational experiences of residents [36]. Many residents have expressed concern about a loss of continuity of care [37] and reduced exposure to operative cases [38].
Considerable unrest with regard to the ACGME-imposed limitations on residents' work hours appears to exist among faculty members as well. Some surveys have shown that the majority of faculty members are now working more, feeling more stress, and spending less time teaching and conducting research [37] because of the ACGME reforms. Up to 73% of faculty members lament that they are now performing duties previously handled by residents [39, 40].
The degree to which sleep deprivation and fatigue affect performance among the more than 4,800 residents in the 465 radiology residency programs in the United States [41] has not been documented. However, surveys of radiology residents have disclosed that 85% reported an improved call experience and 90% reported a better educational experience after ACGME work-hour rules were implemented [42]. Forty-five percent of residents reported that their clinical judgment was better when they worked a single night shift rather than a 24-hour shift. A recently published study measuring the accuracy of preliminary radiographic interpretations rendered by radiology residents off-hours with interpretations rendered by attending radiologists shows an overall major discrepancy rate of 2.6% [43]. The authors acknowledged that their study did not identify the risk factors associated with a discrepant interpretation.
The degree to which facilities with residency teaching programs comply with ACGME requirements is not known with certainty. One survey of more than 4,000 physicians in residency programs in all specialties in the 2003–2004 academic year reported a high degree of noncompliance [44]. On the other hand, ACGME-monitored compliance studies revealed that in the 2005–2006 academic year, the overall compliance rate was greater than 90% [25]; overall, only 8% of all residency programs warranted citations for violation of ACGME requirements, although the percentage exceeded 20% in such specialties as emergency medicine, family practice, internal medicine, neurologic surgery, pediatrics, physical medicine and rehabilitation, plastic surgery, and general surgery. The percentage of radiology programs warranting citations for noncompliance was approximately 8% [25].
Notwithstanding seemingly excellent compliance, ACGME work-hour requirements remain a "festering sore spot for both doctors and hospital administrators," and have had a negative effect on training and patient care, according to a New York magazine journalist [45]. Bertrand Bell, the physician who chaired the New York commission that recommended changes in resident work hours in the aftermath of the Libby Zion death, offered the following explanation for resistance to the requirements.
You have to remember that you're dealing with a firmly entrenched structure for graduate medical education that is essentially unchanged since it was invented at Johns Hopkins over 100 years ago. And if you know anything about these kinds of systems, you know how doggedly they resist change.
The degree to which the ACGME-imposed limits on resident working hours affect patient care, residents, and faculty members is simply not known [46–48]. Two Columbia University Medical Center internists have summarized the status quo this way [49]:
Even if Hippocrates is satisfied and work-hour rules probably do not ultimately harm patients, is the case closed? Not so fast. Little is known about how work-hour limits for residents affect the overall experience of patients and their families, nor how they affect nurses and other members of the health care teams. More important, the implications of the new rules for adequacy of education and training remain uncertain.
Despite uncertainty regarding the value of resident work-hour limitations, even tougher restrictions and consequences for noncompliance may loom on the horizon. In Congress, Representative John Conyers (D–MI) plans to reintroduce a bill that proposes more stringent versions of current work-hour rules. Legislators in New Jersey, Pennsylvania, and Massachusetts have also introduced bills that will further restrict resident working hours [50].
Summary
For more than two decades, the subject of residents' working hours in health care facilities has received intense scrutiny from and has commanded the rapt attention of myriad segments of the public. The ACGME; medical centers that have residency programs; physician faculty members who participate in residency programs; the news media; the courts; and, of course, the residents themselves have all been mired in an unending debate that usually focuses on such questions as do residents work too many hours in a shift or in a week. If they do, do long work hours have detrimental effects on the residents or on the patients to whom they administer care? Do long work shifts lead to impairment due to sleep deprivation that in turn can cause injury to members of the general public? Do reductions and other similar restrictions imposed on resident working hours lead to a deterioration of the residents' learning experience? As a result of ACGME-imposed restrictions on residents' work hours, do faculty physicians have less time for teaching and research?
Finally, are medical facilities liable for injuries sustained by third parties from sleep-deprived or fatigued residents? Would the same courts that imposed liability on a nonmedical business entity for negligent actions in off-duty hours of a nonmedical employee whose mental or physical condition became impaired because of work requirements while on duty rule differently if the employer were a health care facility and the employee an overworked, sleep-deprived resident? Only the courts themselves in future decisions can answer that question with certainty.
Although the answers to these questions are currently unknown, certain facts are known: Long work hours can cause fatigue and sleep deprivation. Sleep deprivation can manifest itself in impaired behavior similar to that caused by alcohol intoxication, both of which are common causes of automobile accidents. That medical centers are liable for negligent conduct of their employed residents is clear-cut. What is not clear-cut is whether liability can be imposed if the negligent conduct of a medical center's residents results in injury to a third-party, such as a motorist involved in an accident caused by a sleep-deprived resident. Although an Illinois Appellate Court declined to impose liability in one instance, readers should be aware that in other states employers have been found to be liable in such circumstances. The degree to which ACGME regulations have improved patient care and reduced errors by residents is not known, and the effect on the quality of resident training is controversial. Nevertheless, residents and resident directors should be familiar with and adhere to pronouncements of the ACGME relative to residents' working hours.
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