reduction in the relative risk for death in 1,268,738 non-surgical patients drawn from a national survey of hospitals. 2011 reform When surveyed about duty hour restrictions, both medical and surgical residents, as well as residency faculty perceive that patient safety hasn't changed or has suffered as a result. Additionally, many residents note an increase in self-reported errors. There are a number of possible explanations for these results. See Problems with duty hour restrictions. Problems with duty hour restrictions It is largely felt that actual duty hours (opposed to reported duty hours) have not changed substantially: prior to the implementation of work hour regulations, residents were already working an average of 82 hours per week. Many studies rely on self-reported hours, but significant bias to under-report duty hours exists for a few important reasons: One is that statutes do not provide whistleblower protections to residents who report work hour violations. Second, the penalty for work hour violation is loss of accreditation, which would adversely affect medical residents and prevent them from becoming board certified. Finally, some residents may be pressured by their residency programs to underreport hours or even punished if they do not. Moreover, these studies – particularly the ones that find favorable results - may fail to account for confounders that positively impact outcomes, including the wide adoption of electronic medical records, a shift toward team-based care, and implementation of best practices. Duty hour regulations may not address the root causes of medical errors, and may inadvertently create new problems that impact patient outcomes. In order to adhere to duty-hour standards, residents must handoff their patients to other residents more frequently, which can lead to miscommunication, interrupted continuity of care and increased errors. Also, most studies show that residents see more patients now, despite having less time, leading to more administrative work and less time for direct patient care and education. One systematic review found that resident learning has been unfavorably impacted by duty hour regulations, and because medical education affects knowledge and competence, this may result in poor decision-making and medical errors. Proposed methods of reducing workloads The most commonly proposed method is regulation of working hours, but this is ineffective if regulations are ignored. Whistle-blower protection laws, protecting residents who report violations of working-hour regulations from losing their residencies and thus their route to professional accreditation, have been proposed. Increasing the bargaining power of residents has been