The Joint Commission has issued a sentinel event alert warning hospitals of the dangers of long hours and fatigue among healthcare workers.

In the Dec. 14 alert, the Oakbrook Terrace, Ill.-based accreditation organization listed many of the hazards associated with extended work hours, including confusion, memory lapses and slowed judgment. The alert also pointed to past research demonstrating a link between residents' and nurses' long shifts and impaired performance.

“An overwhelming number of studies keep saying the same thing—once you pass a certain point, the risk of mistakes increases significantly,” Ann Rogers, a sleep medicine expert and faculty member at Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, said in the alert. “We have been slow to accept that we have physical limits and biologically we are not built to do the things we are trying to do.”

The Joint Commission included a list of nine recommendations, urging hospitals to establish safeguards for patient handoffs, develop fatigue management plans and educate staff about the potential effects of fatigue.

“There are some evidence-based actions that healthcare organizations can take to help mitigate the risks of fatigue that result from extended work hours—and, therefore, protect patients from preventable adverse outcomes,” the Joint Commission said in the alert.

This latest alert is the 48th sentinel event newsletter issued by the Joint Commission. Other recent alerts have focused on radiation from diagnostic imaging, inpatient suicide, hospital violence and maternal death.