July effect

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The July effect, sometimes referred to as the July phenomenon, is a perceived increase in the risk of medical errors and surgical complications that occurs in association with the time of year in which United States medical school graduates begin residencies. A similar period in the United Kingdom is known as the killing season or, more specifically, Black Wednesday, referring to the first Wednesday in August when postgraduate trainees commence their rotations.

United States[edit]

A Journal of General Internal Medicine study, published in 2010, investigated medical errors from 1979 to 2006 in United States hospitals and found that medication errors increased 10% during the month of July at teaching hospitals, but not in neighboring hospitals.[1][2] Surgical errors did not increase, leading to the hypothesis that medication errors are easier for new personnel to make because they are prescribing drugs on their own, rather than being cross-checked by others.[3] The study did not have sufficient data to link the increased errors to new residents, however, and further study would need to be done in order to determine the sources of this increase.[4] A criticism of the study suggests that the supervision of new residents and the patient loads at teaching hospitals have improved since 1979 and that the results may be skewed by including much older data.[5]

Other studies searching for the July effect have found variable evidence of an increased risk, with several studies finding no risk at all.[2]

United Kingdom[edit]

In Britain, there is an influx of newly qualified doctors into the National Health Service (NHS) each August, and this period is associated with an increase in medical errors. The phenomenon has been recognised by Professor Sir Bruce Keogh, medical director of the NHS. The term "Killing Season" originated in the 1994 British medical drama series Cardiac Arrest written by Jed Mercurio (under the pseudonym John MacUre).[17] In an episode first broadcast on BBC1 on 5 May 1994, the character Dr. Claire Maitland consoles a junior who has just committed a fatal error with the dialogue: "You come out of medical school knowing bugger all. No wonder August is the killing season. We all kill a few patients while we're learning."[18][19]

The day when junior doctors typically start work has also been dubbed "Black Wednesday" among NHS staff. A 2009 Imperial College London study of records for 300,000 patients at 170 hospitals between 2000 and 2008 found that death rates were 6 percent higher on Black Wednesday than the previous Wednesday. The study also found that typically fewer patients attended A&E on the first Wednesday in August than the previous week.[20]


  1. ^ Phillips DP, Barker GE (May 2010). "A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents". J Gen Intern Med. 25 (8): 774–779. doi:10.1007/s11606-010-1356-3. PMC 2896592. PMID 20512532.
  2. ^ a b "New residents linked to July medication errors", amednews, 21 June 2010, American Medical Association
  3. ^ National Public Radio (5 July 2010). "July: A Deadly Time For Hospitals". Retrieved 11 August 2010.
  4. ^ "The 'July Effect': Worst Month For Fatal Hospital Errors, Study Finds", ABC News, 3 June 2010
  5. ^ "Valley Dr.: Surgery's `July effect' outdated", KTAR, 17 June 2010
  6. ^ Yaghoubian A, de Virgilio C, Chiu V, Lee SL (2010). ""July effect" and appendicitis". J Surg Educ. 67 (3): 157–60. doi:10.1016/j.jsurg.2010.04.003. PMID 20630426.
  7. ^ Inaba K, Recinos G, Teixeira PG, et al. (January 2010). "Complications and death at the start of the new academic year: is there a July phenomenon?". J Trauma. 68 (1): 19–22. doi:10.1097/TA.0b013e3181b88dfe. PMID 20065752.
  8. ^ Schroeppel TJ, Fischer PE, Magnotti LJ, Croce MA, Fabian TC (September 2009). "The "July phenomenon": is trauma the exception?". J. Am. Coll. Surg. 209 (3): 378–84. doi:10.1016/j.jamcollsurg.2009.05.026. PMID 19717044.
  9. ^ "'July phenomenon' from new residents debunked", amednews, 26 October 2009, American Medical Association
  10. ^ Alshekhlee A, Walbert T, DeGeorgia M, Preston DC, Furlan AJ (2009). "The impact of Accreditation Council for Graduate Medical Education duty hours, the July phenomenon, and hospital teaching status on stroke outcomes". Journal of Stroke and Cerebrovascular Diseases. 18 (3): 232–8. doi:10.1016/j.jstrokecerebrovasdis.2008.10.006. PMID 19426896.
  11. ^ Garcia S, Canoniero M, Young L (May 2009). "The Effect of July Admission in the Process of Care of Patients with Acute Cardiovascular Conditions". South. Med. J. 102 (6): 602–607. doi:10.1097/SMJ.0b013e3181a2f8ca. PMID 19434039.
  12. ^ Dhaliwal AS, Chu D, Deswal A, et al. (November 2008). "The July effect and cardiac surgery: the effect of the beginning of the academic cycle on outcomes". Am. J. Surg. 196 (5): 720–5. doi:10.1016/j.amjsurg.2008.07.005. PMID 18789415.
  13. ^ Englesbe MJ, Pelletier SJ, Magee JC, et al. (September 2007). "Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP)". Annals of Surgery. 246 (3): 456–62, discussion 463–5. doi:10.1097/SLA.0b013e31814855f2. PMC 1959349. PMID 17717449.
  14. ^ Kestle JR, Cochrane DD, Drake JM (September 2006). "Shunt insertion in the summer: is it safe?". J. Neurosurg. 105 (3 Suppl): 165–8. doi:10.3171/ped.2006.105.3.165. PMID 16970227.
  15. ^ Myles TD (November 2003). "Is there an obstetric July phenomenon?". Obstetrics and Gynecology. 102 (5 Pt 1): 1080–4. doi:10.1016/j.obstetgynecol.2003.08.001. PMID 14672490.
  16. ^ Young, John Q.; Ranji, Sumant R.; Wachter, Robert M.; Lee, Connie M.; Niehaus, Brian; Auerbach, Andrew D. (6 September 2011). ""July Effect": Impact of the Academic Year-End Changeover on Patient Outcomes". Annals of Internal Medicine. 155 (5): 309–15. doi:10.7326/0003-4819-155-5-201109060-00354. PMID 21747093.
  17. ^ Aylin, Majeed (24 December 1994), "The Killing Season - fact or fiction?", The British Medical Journal, 309 (6970), p. 1690, doi:10.1136/bmj.309.6970.1690, PMC 2542669, PMID 7819988
  18. ^ Cardiac Arrest The Killing Season, The Internet Movie Database, 5 May 1994
  19. ^ Dillner, Louise (23 April 1994), "Frightening realism", The British Medical Journal
  20. ^ "Will patients really die this week because of new NHS hospital doctors?". The Guardian. Retrieved 28 September 2013.

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