Wake-up call: Are sleepy HCWs a danger to patients and themselves?
May 1, 2007 8 minutes read
Wake-up call: Are sleepy HCWs a danger to patients and themselves?
Joint Commission proposes fatigue goal for 2008
Reducing health care worker fatigue may be one of the most important measures you can take to improve patient safety, according to The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations).
For the third year in a row, The Joint Commission in Oakbrook Terrace, IL, is considering reducing fatigue as one of the 2008 National Patient Safety Goals — the key areas that hospitals should focus on. (See box below.)
Proposed National Patient Safety Goal Health Care Worker Fatigue Goal 18 Prevent patient harm associated with health care worker fatigue. Requirement 18A The organization identifies conditions and practices that may contribute to health care worker fatigue, acknowledges that fatigue poses a risk to patient safety, and takes action to minimize that risk. Rationale for Requirement 18A Health care worker fatigue poses a serious threat to patient safety. Multiple studies have suggested a correlation between health care worker fatigue and serious medical errors. Two sources of error-inducing fatigue have emerged in the literature: Prolonged on-duty periods, and work schedules that disrupt normal circadian rhythms and sleep physiology. The risk for error by nurses who work shifts longer than 12 hours has been reported to increase by two to three times. Similar error risk was seen in nurses who work rotating and variable shift work. Another prospective, randomized study reported a 35.9% increase in the commission of actual medical errors by medical interns on duty for longer than 24 hours. Medical residents who work more than 80 hours per week reported committing more than 50% more errors than those who worked fewer than 80 hours per week. The effect of sleep deprivation on cognitive function and reaction time, two critical areas of human performance, is further demonstrated by fact that 24 hours awake has been shown to create similar impairment to a blood alcohol level of 0.1%. Implementation Expectations for Requirement 18A 1. The organization identifies fatigue as an unacceptable risk to patient care. 2. The organization identifies tasks affected by levels of fatigue. 3. The organization takes action to minimize the impact of fatigue on patient safety including consideration of the following:
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Fatigue already is one issue that should be considered in the root-cause analysis of "sentinel events," or serious adverse events, says Rick Croteau, MD, executive director of The Joint Commission's patient safety initiatives.
"We want this to be on their radar screen," he says. "We want the hospitals to identify the extent of the problem in their organization and to deal with it in whatever ways work best for them."
Other organizations have focused attention on fatigue as a cause of medical error. The American Nurses Association recently issued position statements outlining the nurses' and employers' responsibilities to ensure that nurses are not working while fatigued. ECRI, a nonprofit health services research agency in Plymouth Meeting, PA, issued a risk analysis on Fatigue in Healthcare Workers, largely in response to the proposed Joint Commission patient safety goal. (See editor's note for further information.)
In 2004, the Institute of Medicine addressed fatigue in its report, Keeping Patients Safe: Transforming the Work Environment of Nurses, and the Agency for Healthcare Research and Quality included limiting medical resident work hours as part of its 10 patient safety tips for hospitals.
Fatigue is an issue that The Joint Commission will address eventually, predicts Cynthia Wallace, director of ECRI's risk management publications. "A proactive health care facility would say, 'If not this year, then next.'"
Preventing fatigue-related errors requires nothing less than a culture change. After all, nurses and doctors believe they can work through fatigue and still perform well, says Croteau.
"Well, that's just plain wrong," he says. "Doctors and nurses are people and have the same weaknesses as anyone when it comes to being overtired and are just as capable of making mistakes as a result of fatigue as anyone else. It has nothing to do with commitment.
"This is essentially a safety goal that would recognize the reality and humanity of the caregivers. We can't keep ignoring this anymore," Croteau says.
Staffing and overtime schedules obviously are related to fatigue. But hospitals also may consider policies that limit the duties a health care worker can perform after a certain number of working hours, he says.
"Some tasks are more affected by fatigue than others," says Croteau. "Some of these tasks put patients at great risk than other tasks. By taking fatigue into account when duties are assigned, one can limit the impact of staff fatigue on patients."
For example, a nurse working the end of a long shift or an overtime shift could be assigned patients with lower acuity, he says.
"When health care facilities look at the issue of fatigue, it seems like an overwhelming task," he says. "[They think] 'We're already short-staffed. How do we reduce our overtime when we're already short-staffed?'
"There are little steps, strategies that can be put in place," he says. "Maybe it's just a matter of thinking creatively."
Take steps to combat fatigue
ECRI offers suggestions for reducing the negative effects of health care worker fatigue. (See box below.) For example, bright lighting can help employees combat fatigue and readjust their circadian rhythm, which can be affected by changing from day to night shifts.
Consider safer practices that reduce fatigue Here are some steps identified by ECRI that hospitals can take to reduce fatigue and its impact on patient safety: • Reform work practices. —Promote attitudes toward work that recognize that working while exhausted poses an unacceptable risk. It should not be viewed as a sign of dedication. — Consider establishing part-time residencies and job shares for trainees who are willing to extend the length of their residencies. • Conduct an anonymous worker survey to assess the views of the work force on fatigue, scheduling, and related issues. — Use technology (e.g., computerized sign-out and medication orders) to increase continuity of care and reduce errors. • Keep abreast of the status of state and federal regulations relevant to health care workers' duty hours and mandatory overtime limitations. • Comply with duty-hours restrictions. — Ensure that medical residents adhere to ACGME standards for duty hours. — Ensure that nurses adhere to state regulations for duty hours, where applicable. • Adjust scheduling policies. — Review current scheduling policies and practices and compare them to the limits in proposed federal regulations and state regulations, as applicable. — Work with unions, if applicable, and worker groups to develop new schedules. Whenever possible, schedule duty periods to account for the known effects of sleep physiology. • Consider implementing facility policies to limit the number of continuous duty hours for nurses. • Educate health care workers about fatigue and its effects on patient safety and on their own personal safety. |
Shift changes should move forward with the clock — from day to night, for example — to follow the natural flow of the circadian rhythm.
Hospital policy also should enable employees to speak up when they feel fatigue threatens to impact their performance, says Wallace. "It's [a matter of] creating a culture where working long hours isn't a sign of dedication," she says. "You recognize that it can be risky."
Nurses need to be educated about fatigue and its impact, both in hospital-based safety training and in the nursing school curriculum, says Cynthia Haney, JD, senior policy fellow at the American Nurses Association in Washington, DC.
"I think a lot of health professionals really push themselves beyond their limits," she says. "They'll habitually neglect to take meals and rest breaks and often don't even realize that they are not performing as well as they think they are."
If an employee seems habitually fatigued but isn't working long or rotating shifts, the employee may need a referral to the employee assistance program, says Haney.
The employee may have a sick child at home, or may suffer from chronic fatigue or sleep apnea. While you can't pry into medical or private issues, you can offer resources and respond to concerns about job performance, says Haney. "There are issues involving health care worker fatigue that are beyond the scope of the hospital," she notes.
The ANA focused one position paper on the personal responsibility that nurses have to reduce the dangers to patient safety created by fatigue — which may mean refusing to work overtime that would affect performance and limiting outside jobs that may contribute to fatigue. The ANA also issued a position statement on Assuring Patient Safety: The Employers' Role in Promoting Healthy Nursing Work Hours in All Roles and Settings, which emphasizes that employers should provide schedules and staffing levels that enable nurses to get the rest they need. That includes adequate compensation so nurses don't feel compelled to work overtime or extra shifts, the ANA says.
"We can't consider either of these position statements alone," Haney says. "The responsibility is shared."
Fatigue may lead to liability
Meanwhile, the pressure may build for hospitals to address the issue of fatigue. Some state legislatures have addressed mandatory overtime. But with a closer look at staffing and scheduling, the issue of fatigue may gain greater scrutiny as well, says Wallace.
"Once the public sees the potential for medical errors and their own safety to be tied into health care worker fatigue, I think the issue will be very visible to the public, too," she says.
In 2004, the IOM cited fatigue among nurses as a contributing factor in medical errors. The IOM panel recommended that "state regulatory bodies" should prohibit nurses from working more than 12 hours within a 24-hour period or more than 60 hours in a week.
There are liability issues as well. Risk managers need to aware of fatigue as a cause of medical errors and employee injuries. It also can be a contributing factor if an employee has a car accident while commuting home from an extended shift.
While some hospitals may balk at hiring additional staff to reduce working hours, they need to balance the financial implications – and patient safety consequences — of inadequate staffing, says Croteau.
"There is a lot of evidence in the literature that fatigue leads to more errors. That in itself has a cost," he says.
With its position statements on fatigue, ANA plans to build awareness on the issue, says Haney. "We really hope to widen the discussion beyond the nursing community. We're just at the beginning of really stepping up our efforts on this issue."
(Editor's note: Further information on health care worker fatigue is available from the following web sites: American Nurses Association position statements on fatigue: www.ana.org. The Institute of Medicine report, Keeping Patients Safe: Transforming the Work Environment of Nurses, is available at www.nap.edu/catalog.php?record_id=10851.)
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