Update on The Joint Commission's Sentinel Event Alert on Health Care Worker Fatigue

The Joint Commission has issued a sentinel-event alert saying drowsy health professionals are likelier to be involved in adverse events than their well-rested counterparts. The commission advised the more than 6,500 hospitals and other health care organizations it accredits to take steps to mitigate the risks of such fatigue

Nine ways to give rest to the weary health care worker

In a December 2011 sentinel-event alert, the Joint Commission offered advice to help health care organizations prevent fatigue-related adverse events:

• Review policies to ensure that they address extended work shifts and hours.



• Assess hand-off procedures to ensure that they protect patients adequately.



• Invite staff to take part in designing work schedules to minimize potential
  for fatigue.



• Offer tips to fight fatigue, such as doing things that involve physical action, talking with other people, taking short naps and drinking coffee only when tired.



• Educate staff about sleep hygiene and the effects of fatigue on patient safety.



• Offer opportunities for staff to express concerns about fatigue.



• Use a system of independent second checks for critical tasks and complex patients.



• Consider fatigue as a potential contributing factor when reviewing all adverse events.



• Ensure that the nap room is cool, dark, quiet and comfortable; provide eye masks and ear plugs; and let workers turn off pagers between shifts.

Source: "Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety," The Joint Commission, Dec. 14, 2011 http://www.jointcommission.org/sea_issue_48/