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An exhausted workforce increases the risk of errors

From the June 2, 2005

If you work in healthcare, then you've experienced it: that mind-numbing, body-draining fatigue that makes it difficult or impossible to stay focused on the task at hand or to remain vigilant to patient safety. Perhaps you can relate to the following all-too-typical scenarios:

A nurse who, after a busy 12-hour day shift, is required to stay an additional 4 hours to assist in the care of a patient who has unexpectedly developed serious complications, and then returns early the next morning for another scheduled 12-hour shift.

A nighttime pharmacist who, fighting to stay awake at 5:30 a.m., 11.5 hours after the beginning of his shift, is now required to prepare multiple complex admixtures for an influx of emergency department patients, keeping him onsite for 2 additional hours.

A surgeon who, after a full 12-hour day in the OR, is called back to the hospital that evening to consult on an emergency department patient who needs emergency surgery.

An on-call nurse who, after working 9 hours in the OR, is called back into the hospital to assist with a lengthy emergency surgical procedure, only to return to the hospital the following morning for another 8 hours in the OR.

A pediatric resident who, after a 17-hour workday, is resting in a cramped on-call room when a nurse calls him to attend to a neonate whose condition is rapidly deteriorating.

Long work hours and the fatigue that results represent a serious threat to patient safety. The detrimental effects of fatigue on performance are well documented (see Table 1 at the end of the article).(1-3) In fact, prolonged wakefulness can degrade performance, leaving a healthcare provider with the equivalent of a blood alcohol concentration of 0.1%, which is above the legal limit for driving in most states.(4) When fatigued, performance is also quite variable. One moment it's good, and the next moment it's inadequate as perceptions begin to disengage during microsleeps.(5)

When fatigued, the physiological drive to sleep can result in intermittent lapses in consciousness, or microsleeps, lasting a few seconds to a few minutes, with the eyes open and without the knowledge of the individual.(5) Microsleeps impair performance, often leading to errors due to missed information, or even loss of situational awareness. In one study, a videotaped, sleep-deprived anesthesiologist exhibited behaviors indicative of microsleeps during 30% of a 4-hour case!(6)

Other industries have taken action to defend against the effects of fatigue; however, the healthcare industry in general has largely disregarded the problem, especially with the ongoing shortages of licensed practitioners. Several years ago, the Accreditation Council for Graduate Medical Education limited work schedules for medical residents to 80 hours per week (the European Union allows just a 56-hour weekly limit), and the Institute of Medicine recommended that nurses work no more than 12 hours a day and 60 hours per week, in any combination of scheduled shifts, mandatory overtime, or voluntary overtime.(7) However, more needs to be done.

The Anesthesia Patient Safety Foundation (APSF) has recently called upon its members to work jointly toward reducing fatigue in the practice of anesthesiology. The Spring 2005 APSF Newsletter(8) is devoted to this issue and offers, through the advice of a cadre of experts, the following recommendations to defend against fatigue, which are applicable to all healthcare providers:

Education. Using multiple educational forums, provide practitioners and managers with information about the science of sleep, risks associated with fatigue, mechanisms that underlie sleep disorders and fatigue, circadian rhythm disturbances, and approaches to optimize performance. An assessment of staff perceptions about the impact of fatigue on safety may offer a helpful starting point for ongoing education in this area.

Scheduling. Conduct a fatigue analysis on current staffing patterns, looking at the minimum off-duty time, consecutive work periods, and rest/recovery opportunities. Establish work schedules with off-duty requirements (intended for rest), limitations on hours worked each day and week, and time limitations for specific, potentially fatiguing physical and mental tasks within each work day. Disruptions in circadian rhythms, or our biological clock, can also result in fatigue. Whenever possible, recognize the circadian rhythm principles when designing work schedules. Also establish contingency plans to manage staff who have suffered a particularly fatiguing work schedule and consider themselves unfit to continue work.

Planned naps. Establish policies that sanction planned naps in the workplace for staff prone to fatiguing schedules, and procedures that address the timing of naps and required coverage. Even short naps of 45 minutes have been shown to be beneficial in improving alertness without undue grogginess upon awakening. Create quality accommodations and space for these planned rest periods.

Routine rest and meal breaks. Provide for periodic rest breaks; a 15-30 minute break away from the work area decreases the effects of sleep deprivation. If unable to take breaks, report the inadequacy to supervisors. Good quality meals and nutritious refreshments should be available at all times for healthcare workers, including at night.

Light therapy. Application of higher levels of ambient light has helped reduce the effects of disrupted circadian rhythm for night shift workers. Special facilities may be needed to allow workers to obtain light therapy at designated times, though, since timing is crucial to its success.

Use evidence-based safety practices. While not a replacement for well-rested staff, the use of proven safety practices and technologies such as computerized prescriber order entry, bar coding, and smart pumps may help overcome some of the errors caused by any impairment from fatigue.

Fatigue may never be fully remedied in a healthcare industry that must provide 24 hours of continuous care, but it can be better managed. Nevertheless, human errors will still happen. The best solution will likely require a systems approach that both limits the causes of fatigue on the workforce and reduces the potential for human error.

Table 1. Effects of Fatigue(1-3)

Slowed reaction time

Reduced accuracy

Diminished ability to recognize significant but subtle changes in a patient's health

Inability to deal with the unexpected

Lapses of attention and inability to stay focused

Omissions and neglect of non-essential activities

Compromised problem solving and decision making

Impaired communication skills

Inability to recall

Short-term memory lapses

Reduced motivation

Irritability or hostility

Indifference and loss of empathy

Intrusion of sleep into wakefulness

Decreased energy for successful completion of required tasks

Decreased learning of new activities

Reduced hand-eye coordination


(1) Gillberg M, Kecklund G, Akerstedt T. Relations between performance and subjective ratings of sleepiness during a night awake. Sleep.1994;17(3):236-241.

(2) Linde L, Bergstrom M. The effect of one night without sleep on problem-solving and immediate recall. Psychological Research.1992;54(2):127-136.

(3) Howard S. Fatigue and the practice of medicine. Anes Pat Saf Found Newsletter. Spring 2005;20(1):1-4.

(4) Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388:235.

(5) Rosekind MR, Gander PH, Connell LJ, et al. Crew factors in flight operations X: Alertness management in flight operations. NASA Technical Memorandum # 1999-208780. Moffett Field, CA: NASA; 1999.

(6) Howard SK, Gaba DM, Smith BE, et al. Simulation study of rested versus sleep deprived anesthesiologists. Anesthesiology. 2003;98:1345-55; discussion A.

(7) Institute of Medicine. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press; 2004.

(8) Anesthesia Patient Safety Foundation Newsletter. Spring 2005;20(1):1-24.

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