What’s New in the Patient Safety World

January  2012

Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety



The Joint Commission has just released a new sentinel event alert on healthcare worker fatigue and patient safety. There is a wealth of literature on the effects of fatigue on workers not only in healthcare but in other high risk industries. We’ve done multiple prior columns on the impact of fatigue, shiftwork, etc. on both patient outcomes and adverse personal events for workers themselves (see our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” and our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?”). Drowsiness, fatigue, and sleep deprivation also have an impact on personal health of nurses. The issue of nurses having accidents while driving home from work drowsy is fairly well known (Scott 2007, Dorrian 2006). While that applies to drowsiness after any shift, it is more prevalent after night shifts. Working while tired also predisposes to more needle sticks, stress levels, and other health issues.


The new sentinel event alert focuses on the consequences of fatigue to both patients and workers and has a good review of the literature, primarily from studies on nurses working extended (>12 hour) shifts and studies looking at the impact of long resident duty hours. The alert provides many good recommendations, many of which are common sense and many of which come from studies on fatigue from organizations like NASA.


First, and foremost, they recommend you assess your organization’s risks for fatigue-related events. While virtually all hospitals keep logs of nursing shifts worked, they almost never keep logs of other healthcare workers’ hours (other than resident hours in teaching hospitals). And when was the last time you saw a graphic presentation of hours worked at one of your quality improvement/patient safety meetings or a Board meeting?


Second, they recommend reviewing your organization’s policies, procedures, and practices for handoffs. Handoffs are high-risk times for patients and fatigued staff may make handoffs even more error-prone. But also keep in mind that most interventions for reducing worker fatigue will also increase the number of handoffs that occur, so we are continuously balancing the effects of both.


Third, they recommend having staff provide input into design of work schedules. (But our caveat: Beware that the desired schedules of workers may not eliminate fatigue. Very often nurses prefer 12-hour shifts because it provides them with more personal time. But that does not guarantee they will be functioning any less fatigued.).


Fourth, implement fatigue management strategies. We’ve discussed the value of naps during work shifts on numerous occasions. In our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” we did discuss some of the issues related to working long shifts, varying shifts, consecutive shifts, and night shifts. In that Tip we referred to an excellent 3-part series this year “Is It Time to Pull the Plug on 12-Hour Shifts?” by Geiger-Brown and colleagues. Part 3 of that series contained some great suggestions for protecting nurses working the night shifts (use of “buddy” systems, planned “power naps”, avoiding certain types of tasks during the body’s circadian nadir around 2-4 AM, and encouraging nurses to speak up when they are tired).


In our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?” we discussed a study (Fallis 2011) providing timely discussion about napping on the night shift. Fallis and colleagues provide a detailed discussion about the literature on fatigue and threats to both patient and personal safety in nurses (and other healthcare workers) on the night shift and the literature on the effects of napping on night shifts in multiple industries. They then did focused interviews with 13 experienced nurses working the night shift in the emergency room or ICU setting in a community hospital in Canada. Ten of the 13 described themselves are “regular” nappers on the night shift (meaning that they often took brief naps on scheduled breaks if circumstances permitted). Three major themes evolved: the environmental scan, the impact of napping, and the consequences of not napping. The environmental scan was an analysis of all the variables taken into consideration in making a decision as to whether a nap was feasible. Those included things like how busy the unit was, what the mix of experienced vs. inexperienced nurses was, who was available for relieving them, and whether anyone was working a double shift.


The impact of napping could be positive or negative. Most of the regular nappers noted a positive impact, such as awakening refreshed and able to think more clearly. But naps are not for everyone. One of the downsides of naps is occasionally awakening and temporarily feeling disoriented and slow to respond or the phenomenon of “sleep inertia”. Almost a quarter of the interviewees in the Fallis study mentioned this and it was the primary reason that several of them had become “non-nappers”.


The consequences of not napping included slowed mental processes and “foggy thinking”. Nurses found themselves having to check things multiple times. They gave examples of missing arrhythmias on telemonitoring screens because of decreased vigilance. Many found the period between 4AM and 6AM to be most vulnerable. (Note that almost all studies on fatigue and sleepiness on the night shift do identify a roughly two-hour period where concentration abilities are at their worst but the exact time of that nadir differs from study to study).


The sentinel event alert notes that you must provide the proper environment (including ensuring staff are truly going to be allowed to nap without interruptions) for naps or sleep breaks. In our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?” we noted that putting systems in place to allow napping on the night shift is not easy. First, you have to provide adequate “relief” staffing to ensure full coverage of your units at all times. You already must do this for other breaks (meal breaks, bathroom breaks, etc.) that nurses need on any shift. Most nurses will tell you they often work shifts with no breaks at all because of staffing shortages or mismatches between staffing and patient acuity. Second, you need to provide an appropriate physical environment conducive to taking a brief nap (quiet and comfortable, free from interruptions, yet close enough for the nurse to be aroused to respond to patient care emergencies). Third, you need to have in place a system of prioritization in which naps would be allowed only if all preset criteria are met. And lastly you need to have in place a management culture that recognizes the problem as real and is supportive of efforts to address the problem rather than approach it in a punitive manner.


Many (or most) nurses may have difficulty napping if they have one or more patients who are unstable. One other barrier mentioned by several nurses in the Fallis study was fear of what the public would think about nurses “napping on the job”. Given the news media responses in the recent air traffic controller cases, it is clear that raising public awareness about the dangers of fatigue and the benefits of napping under appropriate circumstances is very important.


In addition to providing for naps, the sentinel event alert recommends things like strategic caffeine consumption, doing something involving physical action, and engaging in conversations.


Fifth, the sentinel event alert recommends educating your staff about sleep hygiene improvement techniques and educating them about the effects of fatigue on patient safety and their own safety.


And the alert notes the importance of your culture of safety. Staff must have the opportunity to express concerns about fatigue and be supported (with action, not just words) when those concerns are raised. They recommend use of teamwork when working extended shifts and use of things like independent double checks for critical tasks. (But another caveat from us: Prior studies in nursing (Dorrian 2006) concluded that less sleep may lead to the increased likelihood of making an error, and importantly, the decreased likelihood of catching someone else's error.)


Lastly, you always need to consider whether fatigue was a contributing factor when you are doing root cause analyses (RCA’s) of untoward events or near misses.



Overall, this sentinel event alert is timely and practical. But also keep in mind that when you do undertake an intervention, be sure that your intervention does not inadvertently increase the problem! See our January 3, 2012 Patient Safety Tip of the Week Unintended Consequences of Restricted Housestaff Hours”.








The Joint Commission. Sentinel Event Alert. Health care worker fatigue and patient safety. Issue #48. December 14, 2011




Scott LD, Hwang W-T, Rogers AE, et al. The Relationship between Nurse Work Schedules, Sleep Duration, and Drowsy Driving. Sleep 2007; 30(12): 1801-1807




Dorrian J, Lamond N, van den Heuvel C, et al. A Pilot Study of the Safety Implications of Australian Nurses' Sleep and Work Hours. Chronobiology International 2006; 23(6): 1149–1163




Geiger-Brown J. Trinkoff AM. Is It Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010;  40(9): 357-9, 2010 Sep




Fallis, WM, McMillan DE, Edwards MP. Napping During Night Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency Department Nurses

Crit Care Nurse March 31, 2011 vol. 31 no. 2 e1-e11
















Tip of the Week Archive


What’s New in the Patient Safety World Archive