Essay

The Impact of Fatigue on

Patient Safety and Risk

Management

Chapter 29

What We Know about Fatigue

The effects of fatigue and sleep deprivation have

been directly linked to increases in the

occurrence of human error.

The Exxon Valdez incident as well as the

disasters at Three Mile Island, Bhopal, and

Chernobyl each lists fatigue as a root cause

What is Fatigue

• Fatigue is not easily defined and people experience different and varying degrees of symptoms

– Generally, fatigue can be described as feelings of extreme tiredness, lacking energy or experiencing exhaustion, to the point that decreases in ability to function and respond as normal result

– Fatigue usually presents when a person is suffering from a lack of quality sleep that over time can adversely affect performance

Impact of Fatigue

• Chronic sleep deprivation can result in a lack of

vigilance, attention and short-term memory lapses,

cognitive slowing and frontal lobe function deficits,

and rapid and involuntary sleep onsets during waking

hours

• Moodiness, emotional instability, clumsiness, lack of

motivation, and even loss of appetite and digestive

problems can also result when a person is chronically

fatigued

Why are Healthcare Providers

Susceptible?

• Many entities in the health care sector operate 24/7 and must be staffed to provide adequate coverage at all times

• Many health care providers, particularly interns, residents and attending physicians are forced to either work long hours as part of their training or return to the hospital after hours to handle emergencies

• Providers work schedules which include various non- traditional types of shifts: evening, night, rotating, shifts of various lengths and on-call

The Eight Hour Work Day is not

Typical in Healthcare

• Many health care professionals routinely work 12 hour shifts and are often required to work longer due to staffing issues. One study gathered data on critical care nurses’ work hours and found over a 28 day reporting period that only 1 in 502 respondents reported leaving work at the end of their scheduled shift

• Long duty hours are infamously associated with residents in training who, until regulations were enforced by the Accreditation Council for Medical Graduate Education (ACGME) in 2003, sometimes worked upwards of 100 hours per week and shifts lasting 36 hours or longer with little time for on-duty sleep

Research: Correlating Fatigue to

Medical Errors

• Research has demonstrated a definitive link between fatigue and a decrease in cognitive function

– the following skills/functions are impaired by fatigue:

• degradation of accuracy and timing,

• multi-tasking becomes difficult,

• ability to integrate information is lost,

• performance becomes inconsistent, and

• even well-practiced activities become increasingly difficult.

– Taken from a study by JA Caldwell, et al., Attention management strategies for operational contexts,

Two Studies Provided Evidence of the

Impact of Fatigue

• Articles titled

– “Impact of Extended-Duration Shifts on Medical Errors,

Adverse Events, and Attentional Failures” and “The

Working Hours of Hospital Staff Nurses and Patient

Safety” each detailed the impact of fatigue on residents and

nurses

– The results of this study demonstrated a correlation in an

increase in the number of significant fatigue-related errors,

including those resulting in a fatality, as the number of

extended-duration shifts increased

External Activities Impacting the

Management of Fatigue

• The case of Libby Zion --Although her death was the result of a culmination of mishaps, contributing factors included that Libby was being cared for only by residents, who routinely worked 36 hours at a time with minimal to no sleep

• Libby’s father turned the tragedy of losing his daughter into a mission aimed at limiting resident work hours and increasing their supervision.30As a result of his crusade, limitations on resident work hours were recommended by a New York state commission in 1987

External or Professional Regulatory

Activities

• In 2003 the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour regulations limiting resident duty hours to an average of 80 hours/week, applicable to all ACGME accredited programs throughout the United States, although there are exemptions for a few specialties

• Similarly, the Association of periOperative Registered Nurses (AORN) and the American Association of Nurse Anesthetists (AANA) have made recommendations intended to limit fatigue in nursing professions and thereby improve patient and provider safety

There have been Opposing Views

Offered to the ACGME Proposal

• Those in favor of limiting

resident work hours believe

it will:

– promote patient

– promote provider safety

– enhance resident well

being

• Those opposed to limiting

resident work hours believe that:

– the extremely long hours

incurred in resident education

are necessary to expose

residents to the rigors of real-

world practice and,

– reducing them will leave the

resident ill-prepared for life

after residency

Additional arguments Opposing

limitations on resident work hours

• Some feel that regulations imposed by an outside agency results in a loss of autonomy by physician training programs.

• Another argument against shorter duty hours is that decreased work hours will result in more frequent patient hand-offs which has a negative effect on continuity of care for the patient.

• In addition, costs associated with implementation of shorter duty hours will require additional staff and this is also a concern to the institutions that sponsor resident training programs.

A Committee from the IOM also

Weighed in on Resident Fatigue

• The IOM committee made the following general recommendations:

– The ACGME should adopt and enforce requirements of resident training that:

• Limits duty hours and develop schedules that allow for prevention of sleep loss and fatigue.

• When fatigue is unavoidable, additional measures should be taken to mitigate the effects.

• Schedules should provide predictable, protected and sufficient recovery sleep to relieve acute and chronic sleep loss.

• Promote resident well-being.

• Ensure learning requirements are met.

IOM Committee Recommendations

• The ACGME should amend its current requirements on moonlighting requiring that all moonlighting be included in the duty hour limits, that the resident get approval for these activities from their program director, and that their performance will be monitored to ensure adequate resident performance.

• The ACGME and residency programs should strengthen monitoring practices and that CMS (Centers for Medicare/Medicaid Services) and TJC (The Joint Commission) should oversee these activities.

• Those institutions with residency programs provide safe alternate transportation options for any resident who is too tired to safely drive home.

• The ACGME should require residency training institutions to adjust resident workload by limiting tasks that provide little or no educational value and providing adequate time for the resident to perform patient evaluations and reflective learning to ensure that the resident fulfills all core educational requirements.

• The ACGME should ensure that there is adequate, direct, onsite supervision of residents.

IOM Committee Recommendations

• Teaching hospitals should institutionalize structured handover processes to ensure continuity of care a patient safety.

• Residents should be fully involved in reporting, learning, and quality improvement systems at their respective institutions and this should be included as part of the educational experience

• All recommendations should be supported by financial stakeholders: CMS, DVA (Department of Veterans Affairs), DOD (Department of Defense), Health Resources and Services Administration, state and local governments, private insurers, and sponsoring institutions, to ensure promotion of patient and resident safety and education.

IOM Committee Recommendations

• ACGME should gather data and monitor implementation of these recommendations as well as plan for revision to achieve the desired result. CMS, AHRQ, NIH (National Institute of Health), DOD, DVA, and others should financially support this effort.

– The IOM published their findings and recommendations in Resident Duty Hours: Enhancing Sleep, Supervision and Safety, Washington, DC: The National Academies Press, 2009.

IOM Committee Recommendations

Alternative Recommendations and

Solutions

• Joint Commission Resources (JCR) recently

published Strategies for Addressing Health

Care Worker Fatigue and names education as

the foundation of raising awareness and

thereby reducing fatigue in the workplace

The Importance of EducationABout

Fatigue –What We Need to Know

• Education should include basic information

about how sleep works, sleep deprivation and

identifying symptoms of fatigue, good sleep

hygiene, identifying sleep disorders, effects of

caffeine, exercise, and prescription drugs on

sleep, as well as environmental conditions that

improve alertness including lighting and

ventilation and taking short breaks from task.

Other solutions to help prevent worker

fatigue

• Other solutions which can be implemented by health care administration include:

– Improving work/rest schedules --taking into consideration shift length, number of consecutive days, start and end times, on-call or overtime, and allowance for adequate recovery time after each worked shift can be very effective in reducing worker fatigue and burnout

– Optimizing sleep,and

– If a person is required to work rotating shifts, ensure that shifts rotate forward to encourage faster circadian entrainment

Staffing Changes

Enhancing the ideas of team work and

effective communication among providers can

also help alleviate the issue of more frequent

patient hand-offs and disruptions in continuity

of patient care, resultant from staffing changes.

By Improving teamwork and communication an organization can

also help to minimize errors associated with fatigue

• According to the Joint Commission organizations can minimize fatigue associated errors by:

– Eliminating the hierarchy, which may be difficult for some physicians. Everyone needs to work as a team and communicate effectively and respectfully with one another.

– Defining each team members’ role and responsibilities.

– Providing training on teamwork and how to communicate effectively.

– Having and enforcing a zero-tolerance policy for abusive behavior, and

– Having a means of measuring team performance.

By Improving teamwork and communication an organization can

also help to minimize errors associated with fatigue

These solutions are relatively easy to

implement and can prove very effective

in preventing fatigue and associated

medical errors, if they are supported by

every person at every level of the

institution.