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Errors and error prevention: A look at recent developments

 Editor's note: This article was written by Sue Dill ­Calloway, RN, MSN, JD, CPHRM, chief learning officer of the ­Emergency Medicine Patient Safety Foundation (EMPSF) and a BOJ ­advisory board member. The article has been reprinted with permission from the fall EMPSF newsletter at

Fatigue has recently been recognized in the medical literature to increase the incidence of adverse events. Fatigue is a widely recognized patient safety issue. Nurses who worked over 12 hours per day or 60 hours per week were found to have made three times the number of medical errors compared to those working standard hours. Many hospitals stopped rotating nurses between days and nights because of the issue of fatigue. Some hospitals quit scheduling nurses for a double shift of 16 hours and then having them back in eight hours to do another shift.

Fatigue has also been associated with cognitive problems, mood alterations, reduced job performance, increased safety risks, and physiological changes. One author said that a review of several hundred studies showed no positive effects from insufficient sleep.

Fatigue is also known to increase residents' risk of making medical errors. The Accreditation Council for Graduate Medical Education (ACGME) in July 2003 implemented reduced work hours for residents. The hours were reduced to a maximum of 30-hour shifts and not more than 80 hours per week.

The ACGME published its final version of resident duty hours July 1, 2011, and included a requirement for honest and accurate reporting of duty hours and patient outcomes. The program must educate ­residents and faculty on the signs of fatigue and sleep ­deprivation, alertness management, and fatigue mitigation processes. The ACGME also recognizes fatigue as a patient safety issue.

Residents who worked a traditional 24-hour shift made 36% more serious errors than residents who worked 16 hours. These resident also made five times as many serious diagnostic errors.

The Joint Commission issued Sentinel Event Alert 48 on December 14, 2011, titled Health Care Worker Fatigue and Patient Safety. The accreditation organization is warning hospitals and others about the potential dangers of healthcare worker fatigue with extended hours and excessive workloads.

The Joint Commission cited several articles supporting the fact that fatigue increases the risk of adverse events and is a patient safety issue. The alert discusses the impact of fatigue. Irritability, impaired communication, lapses in attention and inability to focus, and diminished reaction times are just some of the effects of inadequate sleep or insufficient quality of sleep. Hospitals and other healthcare facilities have been slow to adopt changes to prevent fatigue.

The Joint Commission offers a number of suggestions to reduce fatigue, including creating a fatigue management plan. Staff should be educated on sleep hygiene, which means getting enough sleep, taking naps, and practicing good sleep habits. Assess your schedules and make sure staff members have enough time between shifts to get adequate sleep.

Joint Commission Sentinel Event Alert 48: Health Care Worker Fatigue and Patient Safety, December 14, 2011. Available at

AHRQ Nurses Patient Safety Handbook, Chapter 40, The Effect of Fatigue and Sleepiness on Nurse ­Performance and Patient Safety. Available at

ACGME duty hours 2011 standards. Available at