December 14, 2011
Today, The Joint Commission issued a new Sentinel Event Alert: Health care worker fatigue and patient safety. The Alert urges greater attention to preventing fatigue among health care workers and suggests specific actions for health care organizations to mitigate the risks. An article in the November 2007 issue of The Joint Commission Journal on Quality and Patient Safety reported that nurses who work more than 12-hour shifts and residents working recurrent 24-hour shifts were involved in three times more fatigue-related preventable adverse events. In addition, health care professionals who work long hours are at greater risk of injuring themselves on the job.
The Alert addresses the effects and risks of an extended work day and of cumulative days of extended work hours. The Joint Commission Alert recommends that health care organizations:
• Assess fatigue-related risks such as off-shift hours, consecutive shift work and staffing levels.
• Examine processes when patients are handed off or transitioned from one caregiver to another, a time of risk that is compounded by fatigue.
• Seek staff input on how to design work schedules that minimize the potential for fatigue and provide opportunities for staff to express concerns about fatigue.
• Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue such as engaging in conversation, physical activity, strategic caffeine consumption and short naps.
• Educate staff about good sleep habits and the effects of fatigue on patient safety.
The Joint Commission also suggests that health care organizations encourage teamwork as a strategy to support staff who work extended work shifts or hours. For example, use a system of independent second checks for critical tasks or complex patients. Also, organizations should consider fatigue as a potentially contributing factor when reviewing all adverse events, and educate employees on the importance of good sleep habits, including ensuring their rest environment.