Sleep medicine experts and patient-safety advocates are applauding the Joint Commission's recently issued sentinel event alert, which highlights the hazards of healthcare worker fatigue and offers strategies to mitigate it.
“The first and most important step is raising provider awareness on this issue,” said Dr. Christopher Landrigan, director of the Sleep and Patient Safety Program at 773-bed Brigham and Women's Hospital, Boston, and research director of inpatient pediatrics services at 396-bed Children's Hospital Boston. “There are still a large number of healthcare providers that don't know about the literature showing that fatigue hurts performance.”
Landrigan has authored studies examining the dangerous effects of long work hours. In a 2004 study that appeared in the New England Journal of Medicine, Landrigan and colleagues found that interns in intensive-care units who worked 30-hour shifts on a regular basis made five times as many diagnostic errors and 36% more serious medical errors as those who worked no more than 16 consecutive hours at a time.
In the alert, released Dec. 14, the Joint Commission listed nine evidence-based steps providers can take to lower the risk of harm, including redesigning work schedules, educating staff about the dangers of long hours and encouraging a culture of safety.
“That means everyone has a voice and can communicate effectively,” explained Ana Pujols McKee, the Joint Commission's chief medical officer. “If any member of the team sees an error or something that has been overlooked, they can speak up.”
The alert also emphasized the importance of transitions of care, when responsibility for the care of a patient is transferred from one caregiver to another. “Since patient handoffs are a time of high risk—especially for fatigued staff—assess your organization's handoff processes and procedures to ensure that they adequately protect patients,” the alert said.
The Joint Commission's alert is only the latest in a series of recent efforts to draw attention to the issue of fatigue-related safety risks. In June 2010, 26 experts in medicine, sleep science and patient safety gathered at a conference at Harvard Medical School to discuss ways to implement the Institute of Medicine's 2009 recommendations for resident work hours.
The results of that conference were published in a June 2011 white paper, which included guidance on imposing work-hour limits and redesigning the handoff process.
And in July, new work-hour restrictions and supervisory requirements from the Accreditation Council for Graduate Medical Education went into effect, mandating that junior residents work no more than 16 hours at a time.
But those standards don't apply to other healthcare workers, said Landrigan, one of the authors of the June white paper.
“Although things have changed for the most junior of doctors, other physicians are still allowed to work up to 28 hours at a time, and nurses have no limits,” he said. “That's in stark contrast to other industries that have taken this issue much more seriously and put more safeguards in place.”
Ann Rogers, a sleep medicine expert and faculty member at Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, who worked with the Joint Commission on the alert, echoed Landrigan's concerns about other healthcare workers. Rogers co-authored a 2004 study that found that nurses who worked shifts of 12 hours or longer were three times as likely to make errors.
Changing nurses' work schedules isn't easy, Rogers says, because so many hospitals are already short-staffed and because many nurses favor working fewer but longer shifts, or picking up overtime.
“It's a difficult process,” Rogers said. “Nurses have to provide 24-hour care to their patients and there are often not enough staff.”
Despite the barriers to change, the Joint Commission's decision to include the alert nurses, pharmacists and other healthcare professionals who often work extended hours was a welcome one, said Linda Scott, associate dean of Grand Valley State University's Kirkhof School of Nursing, Allendale, Mich.
“I was very excited to see the alert come out,” said Scott, who co-authored with Rogers the 2004 study on nurse-staffing hours and medical errors. “I'm hopeful it will set the stage for us to use evidence to implement fatigue-management strategies because we need a vigilant workforce and we need to protect our patients.”
And that may require a significant change in hospital policies, extending all the way to organizations' human-resources departments, she added. For instance, nurses caught napping are usually disciplined or fired, Scott said. Instead, she contends that hospitals should acknowledge the probable need for a nap during a long shift and they should make concessions for it.
“It's not just nurses' responsibility to come to work alert,” Scott said. “Hospitals need to partner with their employees and understand that they may need to provide the opportunity to sleep. It's changing the mindset from the old status quo to what is better and safer for everyone.”
Residents, too, are often reluctant to work fewer hours because of fears of missing important on-the-job training opportunities, Landrigan said.
“Five or 10 years ago, there was denial that fatigue even affected performance at all,” he said. “Now there is a greater acceptance that it's an issue, but there are concerns about practical problems, like communication and education. In my view, these are surmountable, and if we are serious about safety, we have to do it.”
