Manage staff fatigue to improve patient safety

Part 2 of 2

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Worker fatigue can adversely impact every aspect of health care performance. High levels of fatigue cause reduced productivity and an increased risk of adverse events. Fatigued caregivers may not think clearly, which is vital to making patient care decisions. Tired people often are unaware that they are not functioning as safely as they would be if they were not fatigued. Shift work and extended hours are common work practices in health care facilities, and yet these practices are known to contribute to higher levels of staff fatigue. Reducing the patient safety risks caused by staff fatigue requires action on the part of management and workers. It is the responsibility of managers to protect staff from the adverse effects of fatigue. It is the responsibility of staff members to ensure that they are fit for duty during their work time.

A 2007 National Patient Safety Goal (NPSG) proposed by the Joint Commission relates to preventing patient harm associated with health care worker fatigue. If it is selected as one of the 2007 NPSGs, health care organizations will be expected to identify conditions and practices that may contribute to worker fatigue, implement processes to identify fatigue that poses a threat to patient safety, and take action to minimize that risk. Implementing this goal will involve three steps:

  1. Identify hazards and associated risks.
  2. Implement control measures to prevent or minimize the risks.
  3. Measure the effectiveness of control measures.

The first step when managing staff fatigue is to identify factors within the workplace that may contribute to fatigue. One particular factor that should be considered carefully is staffing. It is important to determine if staffing decisions are providing people with sufficient opportunity for rest and recovery between shifts. Consider the following:

  • Length of time worked. The length of shifts worked can contribute to fatigue.
  • Previous hours and days worked. The effects of fatigue are cumulative; therefore, people may be sleep deprived due to the previous hours and days worked.
  • Type of duties. Pay particular attention to the level of physical and/or mental effort that is required
  • Time of the day when the work is being performed. Disrupting the body’s circadian rhythms can cause fatigue and also affect performance.

One way to identify workplace factors that contribute to fatigue is to consult with staff members. Ask them if they regularly feel fatigued. Also ask about any near misses they have encountered. Review patient incident reports, paying particular attention to incidents that occur during periods of high staff fatigue (e.g. during the latter half of shifts or during the night – particularly 2 am to 6 am).

Once potential hazards are identified, the associated risks should be analyzed. It is impossible to eliminate all factors that contribute to staff member fatigue. Therefore it is important to prioritize the risks associated with the hazards. Risk is the likelihood that patient safety will be compromised because of the factors that contribute to fatigue. To assess risk, consider both likelihood and consequences. For instance, what is the likelihood that an incident will occur when people are asked to work an extra four hours beyond an eight-hour shift? And if an incident does occur, what would be the consequence (e.g. catastrophic, major, moderate, and minor)? Because health care professionals work in diverse environments job-specific factors must be taken into consideration when prioritizing risks, such as:

  • How often do error-prone situations occur? Generally the more often a fatigued worker must do a high-risk task, the more likely a mistake will be made.
  • How many fatigued staff members are working at the same time? The greater number of staff members who may be fatigued, due to long hours or shift work, the more likely an incident is to occur.
  • What are the skills and experience of the fatigues individuals? Well-trained, competent staff may be better able to adequately perform work-related tasks and self-manage their fatigue.
  • How long are individuals exposed to fatigue? The longer people are fatigued, the more likely an error will occur.
  • What is the level of risk inherent in the job? Fatigue-related incidents are more likely to occur in high-stress, fast-paced environments.

Implement control measures

The third step when managing worker fatigue involves selecting and implementing control measures to reduce risks. The ideal solution when managing fatigue is to completely eliminate contributing factors. However, often this is not possible. The second-best option is to reduce the effect of contributing factors, such as:

  • Redesign patient care practices so that night shift workers have more time to focus on completing core duties.
  • Schedule later shift start times for those people who need maximum sleep time before starting work.
  • Consider night shifts that are shorter than day or evening shifts.
  • Rotate jobs for people doing repetitive or monotonous tasks.
  • Provide sufficient supervision during periods of high worker fatigue (such as night time or in the latter half of shifts).
  • Develop contingency plans for relieving a fatigued staff member from work activities when there is considerable risk to patient safety.
  • Implement strict safeguards (e.g. double checks) for high-risk tasks performed during those times when people are most likely to be fatigued.
  • Require that staff take regular 10-15 minute breaks away from their work station and monitor compliance with this requirement.
  • Provide exercise equipment to allow staff to release tensions and build stamina during their break periods.
  • Educate staff about the effects of fatigue on their personal health and how overly-tired workers also threaten the safety of patients.
  • Implement and communicate to employees an organizational policy that clearly states staff are personally responsible for making appropriate use of their rest days and are expected to arrive at work fit for duty.
  • Make it clear that staff members are expected to notify their supervisor if they have any potential impairment (including fatigue) that may increase their chance of making mistakes.
  • At department or unit meetings, discuss actual patient incidents that may have been caused by staff fatigue. Research shows that many health care professionals report feeling fatigued but that it does not affect their work. Storytelling among staff can help overcome this complacency.
  • Establish a "fatigue hotline" where employees can seek counseling and advice about strategies for managing fatigue. An individual with knowledge of sleep and fatigue principles should staff the hotline.
  • Provide a napping or quiet room to allow staff to take a rest break before beginning the second half of their shift.

The final step in managing worker fatigue is to monitor and review the effectiveness of control measures. Have the chosen control measures been implemented as planned? Are the measures working? Are there any new problems? This evaluation can be undertaken by consulting with staff members, supervisors, the risk manager or patient safety officer, and other individuals or groups involved in patient safety improvement. Also, monitor patient incident reports to assess the incidence of fatigue-related events. There should be a process for ongoing monitoring and evaluation of workplace fatigue and its impact on patient safety.

Health care organizations are just beginning to understand fatigue-related patient safety risks and implement strategies for reducing these risks. The obvious answer might be to reduce work hours for staff. However, limits on work hours may not be possible. Plus, work hours are not the only factor affecting staff performance. Tools and strategies also must be aimed at reducing workplace factors that increase the risk of fatigue-related errors. This can include specific staff training programs, redesign of job responsibilities to "fatigue-proof" risky tasks, and managing workload differently.