Patient Safety Tip of the Week

December 21, 2010    More Bad News About Off-Hours Care



Each year as we wish our readers Happy Holidays we always remind them to be extra vigilant for patient safety issues over the holidays. Nights and weekends are times prone to patient safety incidents and many of the factors that come into play over holiday vacations may further increase the risk of such incidents.


We’ve published several columns highlighting the untoward events that tend to occur on nights and weekends and some of the reasons why:


But in the past month or so we have seen a flurry of articles further demonstrating the occurrence of adverse outcomes “off-hours”.


The abstract of a study presented at the recent American Society of Neprhology annual meeting (Sakhuja 2010) showed that patients with end-stage renal disease (ESRD) admitted on weekends were 17% more likely to die in the hospital than those admitted on weekdays, even after adjustment for other factors. Time-to-dialysis was also 0.29 days longer in patients admitted on weekends.


Stroke fatality rates are also higher for patients admitted on weekends compared to weekdays (Fang 2010). A number of previous studies had also demonstrated increased stroke mortality in patients admitted on weekends (and some also demonstrated increased mortality for those admitted on weekday nights). But the new study was also able to determine factors related to stroke severity and quality of care measures. They did show that stroke severity probably contributes, since more patients with moderate or severe strokes were admitted on weekends. But even after adjustment for stroke severity and a number of other clinical and demographic factors, the stroke fatality rate was 17% higher for those patients admitted on weekends (remarkably similar to the 17% higher mortality rate for ESRD patients noted above). And several key measures of quality of care (eg. percentage receiving neuroimaging, time to neuroimaging, percentage admitted to stroke units, percentage receiving dysphagia testing) were no different in those admitted on weekends.


A study presented at the 2010 American Heart Association annual scientific sessions (Penn Medicine press release) also showed that the quality of hospital CPR is worse at night. Mean chest compressions per minute were fewer in CPR administered during nighttime hours and chest compressions were stopped for longer intervals before and after defibrillation attempts. The authors note a number of factors that might contribute to this, including staff fatigue, lower staffing levels, lack of supervision from supervising physicians, etc. They offer helpful suggestions about potential ways to improve on CPR, such as simulations, use of CPR devices that provide real-time feedback, debriefings, and more supervising physician involvement.


In a recent study (Wu 2010) the incidence of neonatal encephalopathy was higher for babies born at night (defined as between 7:00 PM and 6:59 AM) and highest for those born between 10:00 PM and 4:00 AM. Two previous studies using large national databases have looked at the influence of time of day and day of the week on perinatal outcomes. Previously, a Scottish study (Pasupathy 2010) showed about a 30% increased neonatal mortality for full-term deliveries taking place at all times other than Monday thru Friday from 9 AM to 5 PM. This was largely explained by an increased number of deaths attributed to intrapartum anoxia. After excluding elective Caesarean sections, the difference was attenuated but a significant association between time of delivery and outcome persisted. A Dutch study (de Graaf 2010) found increased perinatal mortality and an increase in a combined perinatal adverse outcome measure in nontertiery hospitals during the evening and night and in tertiary hospitals at night. On the other hand, a previous study (Caughey 2008) showed no difference in neonatal morbidity and mortality by time of day in neonates delivered at term and a study of cesarean sections (Bailit 2006) showed no increase in complications related to time of day.


A recent paper on delays in brain death examinations and the impact on organ donation (Lustbader 2010) showed a 26% weekend drop in brain death examinations and a longer interval between examinations where 2 examinations were required. Both led to a substantial drop in the number of organs available for donation.


Even primary care settings are prone to patient safety incidents (Smits 2010) during off-hours. These authors found an incident rate of 2.4% for patients who had contact with their general practice cooperatives in the Netherlands. Though most incidents did not result in harm to patients, some did have consequences for patients such as additional testing or hospitalizations. Age of patients was significantly related to incident occurrence, with the rate increasing by 1.03 for each year increase in age.



The differences between the hospital during weekday daytime hours and the hospital at night and on weekends is striking. Staffing patterns (both in terms of volume and experience) are the most obvious difference but there are many others as well. Many diagnostic tests are not as readily available during these times. Physician and consultant availability may be different and cross-coverage by physicians who lack detailed knowledge about individual patients is common. You also see more verbal orders, which of course are highly error-prone, at night and on weekends.


In our July 20, 2010 Patient Safety Tip of the Week “More on the Weekend Effect/After-Hours Effect” we noted a study from the UK (Temple 2010) suggesting a physician component as well is part of “the weekend effect”. The study found the death rate at hospitals across England increased by 7% at weekends over the 2005-06 period. They ascribed the increased mortality rates on weekends to primarily two causes: (1) reliance on more junior physicians and (2) lack of specialist services. A systematic review and meta-analysis (Canallazzi 2010) found that there is an increased risk of death for patients admitted to an ICU over the weekend (about 8%) but not for those admitted at night. They suspect that organizational and staffing issues may explain the increased risk on weekends and note factors such as decreased physician-to-patient ratios, unavailability of board-certified intensivists, physician fatigue, and difficulty obtaining complex diagnostic tests as possible contributing factors.


But often it is the difference in non-clinical staffing that is a root cause. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. Even in those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders. You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. They even end up doing some housekeeping chores. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”).


One factor often overlooked is the impact of shift work. Both nurses and physicians often work in shifts where the time of day worked varies and it is clear that such practices may have a number of detrimental effects in any industry. A nice discussion of this was provided in an article by the BMA Scottish Junior Doctors Committee. Though that paper was aimed at the hours worked by residents, they discuss the implications of shift work in numerous industries and the potential impact on safety and the potential health implications. One statistic they quote is that the estimated risk of reported adverse incidents in industry increases to 6% on the second night shift, 17% on a third, and 36% higher risk on a fourth night shift worked (the corresponding numbers for consecutive day shifts are 2%, 7% and 17%).


Quality/safety-guru-turned-hospital-CEO David Shulkin, M.D. described what he saw when rounding on nights and weekends at his hospital (Shulkin 2008). He describes many of the same observations we have noted above. But he really stresses the value of doing those rounds off-hours. One of our most successful patient safety activities is our Patient Safety Walk Rounds but we still tend to do the bulk of those walk rounds during day shifts Monday thru Friday rather than at our most vulnerable times. Shulkin also stresses the importance of involving front line staff, clinical leadership and administration in addressing these vulnerabilities. And he developed a tool, the SWAN (Safety on Weekends And Nights) tool, that we highly recommend all hospitals should use. It is basically a checklist that looks at the various services and practices in your organization that have an impact on quality and patient safety at night and on weekends. It is a good exercise you should do with collective group of your hospital’s clinical and administrative leaders. It can be a real eye opener!




What should you be doing at your organization? We suggest the following:

  • Do some of your Patient Safety Walk Rounds at night and on weekends
  • Do an organizational assessment using David Shulkin’s SWAN tool
  • Develop other means of directing visitor traffic in the hospital (better signage, use of volunteers, etc.)
  • Make sure that ancillary staff have access to physician “on-call” schedules so they may directly call physicians with results or questions rather than unnecessarily involving nursing staff as intermediaries
  • Give your physicians access to CPOE outside the hospital so they may enter orders directly rather than calling in verbal orders
  • Make your decisions about non-clinical staffing take into account the indirect effects on clinical staffing
  • Identify those critical services that need to be available 24/7
  • Keep track of quality/safety statistics related to time of day



We have an incredibly long way to go in resolving the disparities in care we deliver between “normal hours” and “off hours”.






Sakhuja A, Kumar N, Nanchal RS, Dall AT, Kumar G. Weekend Admissions Predict Higher Mortality in Patiens with End Stage Renal Disease (abstract). American Society of Neprhology 2010;  Annual Meeting 2010. J Am Soc Nephrol 2010; 21: 11A




Fang J, Saposnik G, Silver FL, Kapral MK for the Investigators of the Registry of the Canadian Stroke Network. Association between weekend hospital presentation and stroke fatality. Neurology 2010; 75: 1589-1596



University of Pennsylvania news release. Penn Study: Hospital CPR Quality Is Worse At Night. Findings Reveal Potential Cause of Lower Survival from Nighttime In-Hospital Cardiac Arrest. Nov. 14, 2010



Wu YW, Pham TN, Danielsen B et al. Nighttime delivery and risk of neonatal encephalopathy. American Journal of Obstetrics & Gynecology 2010; published online 12 November 2010



Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GCS. Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ  2010;341:c3498, doi: 10.1136/bmj.c3498 (Published 15 July 2010)


full text:



de Graaf J, Ravelli A, Visser G, Hukkelhoven C, Tong W, Bonsel G, Steegers E. Increased adverse perinatal outcome of hospital delivery at night. BJOG 2010; 17: 1098–1107



Caughey AB, Urato AC, Lee KA et al. Time of delivery and neonatal morbidity and mortality. American Journal of Obstetrics & Gynecology 2008; 199(5):496.e1-496.e5



Bailit JL, Landon MB, Thom E et al. The MFMU Cesarean Registry: Impact of time of day on cesarean complications.American Journal of Obstetrics & Gynecology 2006; 195(4): 1132-1137



Lustbader D, O'Hara D, Wijdicks EFM,  et al. Second brain death examination may negatively affect organ donation. Neurology 2010;

Published online before print December 15, 2010, doi: 10.1212/WNL.0b013e3182061b0c Neurology December 15, 2010 WNL.0b013e3182061b0c



Marleen Smits M, Huibers L, Kerssemeijer B, et al. Patient safety in out-of-hours primary care: a review of patient records. BMC Health Services Research 2010, 10:335



Temple J. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. May 2010



Cavallazzi R, Marik PE, Hirani A, et al. ssociation Between Time of Admission to the ICU and Mortality: A Systematic Review and Metaanalysis.

Chest 2010; 138: 68-75



BMA Scotland. Shift-work, Rest and Sleep: Minimising the Risks

Discussion paper by the BMA Scottish Junior Doctors Committee

February 2010



Shulkin DJ. Like Night and Day — Shedding Light on Off-Hours Care. NEJM 2008; 358:2091-2093



Shulkin D. SWAN tool.















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