The Joint Commission is casting a new spotlight on prevention of workplace fatigue, while suggesting ways that health care organizations can mitigate the risks.
In December, the commission released "Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety," which highlights the cumulative effects of being on duty for prolonged periods.
The Joint Commission urges hospitals to assess fatigue-related risks such as off-shift hours, consecutive shifts and staffing levels. Seeking employee input in scheduling also would help minimize the potential for fatigue that may contribute to medical errors.
"Health care workers should be able to speak up if they recognize that they are fatigued," says Ana Pujols-McKee, M.D., the commission's executive vice president and chief medical officer. "We're encouraging the leadership of an organization to engage in a healthy dialogue with the clinical staff."
Employee surveys, which can be conducted anonymously, may pinpoint areas of concern. McKee suggests asking, "How is your unit or your unit manager addressing issues related to fatigue?"
Exertion can adversely affect the transition of a patient from one team of caregivers to another at the end of a shift. To facilitate the process, she says, "a sign-off sheet or electronic tools with all the critical information" would be helpful, "so it's not left to someone's memory."
A fatigue management plan is another important step cited in the Joint Commission's alert. The plan would incorporate scientific approaches to fighting fatigue — engaging in conversation, physical activity, strategic caffeine consumption and short naps. It also would educate staff about good sleep habits and fatigue's impact on patient safety.
"Managing fatigue is a shared responsibility of both hospitals and providers," says Christopher Landrigan, M.D., director of the sleep and patient safety program at Brigham and Women's Hospital in Boston. While hospitals should limit shift length and weekly hours, providers themselves need to make sleep a priority and come to work fully alert.
For night-shift employees, laboring against the body's natural clock can induce fatigue even more easily. "All the research shows we're very poor at identifying when we're tired," says Ann E. Rogers, R.N., a sleep medicine expert at Emory University in Atlanta. "A lot of people around us can see the effects, but we don't perceive them."
As a safety precaution, a hospital could institute a policy prohibiting employees from working more than three or four consecutive nights. Overtime would be monitored, and health professionals who are called in at night wouldn't be expected to work their scheduled 12-hour shifts the following day, Rogers says.
Hospitals also "should make sure they've got enough staffing to cover breaks, because breaks do increase alertness," she says. "Our data show that at least nurses rarely get adequate breaks when they work."
The Agency for Healthcare Research and Quality applauds the commission's raising awareness of fatigue-related risks. "We're all subject to the limits of human physiology," says Jeff Brady, M.D., patient safety portfolio lead at the agency.
"Everyone has some decrease in their function if they've worked too many hours."