Study Highlights Need for Healthcare Facilities to Address Worker Fatigue

Between June 2004 and August 2013 Pennsylvania healthcare facilities reported 1,601 events involving healthcare worker fatigue to the Pennsylvania Patient Safety Authority (PPSA), an independent state agency charged with reducing medical errors, according to a Patient Safety Authority news release.

Of the 1,601 events, 37 Serious Events resulted in patient harm, including four patient deaths.

The report underscores the need for healthcare facilities to develop fatigue risk-management systems (FRMSs), which are comprehensive fatigue-mitigation practices that are data-driven and scientifically based.

In healthcare and other industries, hours-of-service standards, such as those used for residents in training, are commonly employed but do not address all aspects of fatigue.

“Recent literature shows that one of the first efforts made to reduce events related to fatigue was targeted to limiting the hours worked,” said Theresa V. Arnold, manager, clinical analysis for the PPSA. “However, further study suggests a more comprehensive approach is needed, as simply reducing hours does not address fatigue that is caused by disruption in sleep and extended work hours.”

Current Nursing Fatigue Guidelines

According to Arnold, 12-hour shifts are the norm at many hospitals and are often chosen by nurses to limit the number of days they work in a week.

Currently, recommendations that nurses limit their work hours to 60 hours per week or 16 hours in a 24-hour period are generally voluntary, writes Deborah Dubeck (RN, MPH) for the PPSA.

The Institute of Medicine (IOM) recommends that state regulatory agencies prohibit nurses from working more than 12 hours in a given 24-hour period and more than 60 hours in a seven-day period.

Research to date, however, has failed to identify fatigue thresholds that lead to objective performance changes in nurses, making it difficult to know the exact level of fatigue beyond which staff no longer practice safely.

A nurse fatigue professional issues panel convened by The American Nurses Association (ANA) is expected to release a position paper on fatigue later this year. The paper will be a revision of the ANA’s 2006 position statement on nursing fatigue.

Most Events Were Medication Errors, Errors Related to a Procedure, Treatment, or Test

Among all events reported to the PPSA with healthcare worker fatigue as a contributing factor, 62.1 percent involved a medication error and 26.4 percent involved a procedure, treatment, or test error.

“The top five locations in which events occurred were the medical-surgical unit, emergency department, pharmacy, general medical ward, and the laboratory,” Arnold said. “The most common medication errors made involving healthcare worker fatigue were wrong dose given, dose omission, and extra dose given. The most common errors related to a procedure, treatment, or test were laboratory errors, and other miscellaneous errors included radiology or imaging problems and surgical invasive procedure problems.”

The need to prevent medical errors of all types and causes was brought into focus by a new study that estimates the number of patient deaths at U.S. hospitals annually to be 440,000 –more than four times higher than the previously accepted estimate of 98,000. The study author notes that serious harm may be 10- to 20-fold more common than lethal harm.

A 2004 study published in Health Affairs of 393 nurses working more than 5,300 shifts showed that those who worked shifts of 12.5 hours or longer were three times more likely to make a patient-care error. Similarly, a 2007 article published in the Joint Commission Journal on Quality and Patient Safety indicated that physicians-in-training who work recurrent 24-hour shifts make 36 percent more serious medical errors than those residents who work no more than 16 consecutive hours.

“An overwhelming number of studies keep saying the same thing – once you pass a certain point, the risk of mistakes increases significantly,” said Ann Rogers in an American Medical News article. Rogers is a sleep medicine expert at Emory University’s Nell Hodgson Woodruff School of Nursing. “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.”

Sources:

• Patient Safety Authority – Healthcare Worker Fatigue is Cited as a Contributing Factor in Over 1,600 Events Reported to the Pennsylvania Patient Safety Authority
• Pennsylvania Patient Safety Advisory – Healthcare Worker Fatigue: Current Strategies for Prevention
• American Nurses Association  – Assuring Patient Safety: The Employers’ Role in Promoting Healthy Nursing Work Hours for Registered Nurses in All Roles and Settings
• Health Affairs – The working hours of hospital staff nurses and patient safety
• The Joint Commission Journal on Quality and Patient Safety – Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance
• American Medical News – Hospitals alerted to fatigue’s dangers