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
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
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
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
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
Irritability or hostility
Indifference and loss of empathy
Intrusion of sleep into wakefulness
Decreased energy for successful completion of required
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
(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.