ObjectivesTo examine the relationship between perceived and biological stress and near misses among Emergency Medicine residents.DesignSelf-rated stress and stress biomarkers were assessed in residents in Emergency Medicine before and after a day shift. The supervising physicians and residents reported numbers of near misses.SettingThe study took place in the Emergency Department of a large trauma 1 centre, located in Detroit, USA.ParticipantsResidents in Emergency Medicine volunteered to participate. The sample consisted of 32 residents, with complete data on 28 subjects. Residents’ supervising physicians assessed the clinical performance of each resident.Primary and secondary outcome measuresParticipants’ preshift and postshift stress, biological stress (salivary cortisol, plasma interleukin-6, tumour necrosis factor-alpha (TNF-α) and high-sensitivity C-reactive protein), residents’ and supervisors’ reports of near misses, number of critically ill and patients with trauma seen during the shift.ResultsResidents’ self-reported stress increased from an average preshift level of 2.79 of 10 (SD 1.81) to a postshift level of 5.82 (2.13) (p<0.001). Residents cared for an average of 2.32 (1.52) critically ill patients and 0.68 (1.06) patients with trauma. Residents reported a total of 7 near misses, compared with 11 reported by the supervising physicians. After controlling for baseline work-related exhaustion, residents that cared for more patients with trauma and had higher levels of TNF-α reported a higher frequency of near misses (R2=0.72; p=0.001). Residents’ preshift ratings of how stressful they expected the shift to be were related to the supervising physicians’ ratings of residents’ near misses during the shift.ConclusionResidents’ own ratings of near misses were associated with residents’ TNF-α, a biomarker of systemic inflammation and the number of patients with trauma seen during the shift. In contrast, supervisor reports on residents’ near misses were related only to the residents’ preshift expectations of how stressful the shift would be.

Objective Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review report suggests that residents in clinical learning environments underreport their near-misses, an indicator of patient safety. Furthermore, when the residents report these events, they receive little feedback from their attendings. Although, various studies emphasize the importance of feedback given to the residents, the association between feedback and patient safety has not been explored. This study was conducted in 28 emergency medicine residents in a level 1 trauma center. A recent study in the same cohort found that residents’ stress biomarker levels and patient acuity were positively related to their near-misses reports. The current study hypothesizes that residents that receive constructive feedback on their performance from their attendings would report more near-misses. Results Linear regression was used to determine whether ratings of attendings’ feedback predicted residents’ reports of near-misses. Feedback was positively related to residents’ near-misses reports even after controlling for patient acuity and stress biomarker levels. This may be due to the residents becoming more aware of what a near miss is or it may also be that constructive feedback encourages them to report more near-misses as they may view this as a learning opportunity.