By Greg Freeman, Special to AHC Media


Nurse and staff member fatigue increasingly is recognized as a significant threat to patient safety. Risk managers should adopt strategies to reduce fatigue caused by scheduling, overtime, and excessive workloads.

• High turnover rates among nurses can indicate fatigue risks.

• Hospital culture must encourage staff to admit fatigue and to report fatigue in others.

• Creative scheduling can reduce nurse fatigue.

When fatigue is addressed in the healthcare workplace, attention often goes first to physicians and particularly medical residents who are sleep-deprived and overworked. Increasingly, risk managers are focusing on the patient safety threats posed by nurses and other staff members who are too tired to do their jobs properly.

Fatigue poses a “huge” threat to patient safety, says Richard C. Boothman, JD, chief risk officer and executive director of clinical safety at the University of Michigan Health System in Ann Arbor. The healthcare industry has not connected the dots between how clinical and business pressures can fatigue nurses to the point of threatening patient safety, he says.

“Fatigue is a pretty well documented concern, but it is not often related to nurses,” Boothman says. “We went through years of worry about resident work-hour restrictions, and we keep meticulous records of how many hours residents work, and truck drivers are under some stringent restrictions. There is no reason to think nurses are immune to the same problem, and in some ways it’s worse.”

The problem can be worse because nurses have the most direct contact with patients, and fatigue-induced errors or oversights can start a chain reaction of improper care, Boothman explains. Nurses also can be more susceptible to fatigue than residents because the nurse is working constantly through the shift, unlike residents who work long hours but can rest when they have time, he says.

Boothman cites the infamous case of a highly regarded obstetrics nurse at St. Mary’s Hospital in Madison, WI. In 2007, she worked her regular eight-hour shift on July 4 and volunteered to work an extra shift that same day. Scheduled for a 7 a.m. shift on July 5, she slept at the hospital at the end of the two shifts. During the second half of that July 5 shift, the nurse mistakenly gave intravenous bupivacaine (Marcaine, Sensorcaine) to a 16-year-old scheduled for induction of labor. The anesthetic, intended for epidural administration, had not been ordered. She was supposed to have given intravenous penicillin that had been prescribed to treat a streptococcal infection. The woman died from cardiac arrest, but her baby lived.

The nurse was charged initially with a felony, “criminal neglect of a patient causing great bodily harm,” but was allowed to plead no contest to two misdemeanors. The Wisconsin Board of Nursing suspended her license for nine months, and she lost her job.

“Most of us in the business thought that treatment was incredibly unfair,” Boothman says. “The hospital dangled financial incentives for her to work back-to-back or really long shifts.”

The hospital determined that fatigue was one cause of the error, and it implemented a policy to limit hours worked. It also took several steps to improve the safety of medication administration, St. Mary’s reports. (For more on the incident and the hospital’s response, see the story “Shaping systems for better behavioral choices: Lessons learned from a fatal medication error,” Joint Commission Journal on Patient Safety and Quality, April 2010.)

Comparable to alcohol

Risk managers must convince hospital leaders to see nurse fatigue as a patient safety risk, rather than a budgetary or human resources problem, Boothman says. Staffing ratios and scheduling should always factor patient safety into the decision-making process, he says.

“We’ve had blinders on about this for a long time,” Boothman says. “Ironically, part of the problem is brought on by the caregivers, because they seem so dedicated that they often put their own health and concerns off to the side.”

Naturally, the problem is more common and more serious in those settings that provide patient care 24 hours per day or those that require mandatory overtime, says Robin Diamond, MSN, JD, RN, senior vice president of patient safety and risk management at The Doctors Company, a malpractice insurer based in Napa, CA. But any setting is affected if staff are fatigued, whether it’s by work schedules or a new baby at home, she says. The risk comes from attention lapses, inability to focus, slow reaction time, and confusion.

“Objective recordings by polysomnographic recorders verify that nurses, air traffic controllers, and even commercial truck drivers regularly fall asleep during night shifts,” Diamond says. “Research has shown a significant relationship between sleep in the prior 24 hours and the risk of making an error. Some studies are comparing impairment to blood alcohol content, suggesting that a nurse awake for 19 hours is the same as having a blood alcohol content of 0.05%.”

According to a study by Australian researchers, there is a 3.4% chance of an error occurring when nurses obtain six hours or less of sleep during a 24-hour period. This number might sound small, but Bette McNee, health and human services technical specialist with The Graham Company, a healthcare consulting firm in Philadelphia, PA, makes this point: If an average teaching hospital has 1,000 nursing shifts per day, this error percentage equals 34 daily errors. Over a year, that’s more than 12,000 patients whose care is at risk because nurses aren’t getting adequate sleep. (An abstract of the study is available online at

“The most important thing a hospital can do is to create a culture that allows a nurse to say that he or she is tired and needs to take a short nap or a walk outside — a culture where the nurse doesn’t worry about reprimand or disciplinary action for recognizing their own limitations,” McNee says.

A punitive atmosphere will drive fatigue issues underground, says Brandi Crow, BSN, RN, who worked until recently as associate chief nursing officer at a major hospital and is now clinical analyst with MD Buyline, a company based in Dallas that provides information to make technology decisions. She recalls incidents in which a nurse and a physician were routinely too fatigued to provide safe care.

“We found that coworkers, everyone around these two individuals in their department, were really hesitant to report or confront the behavior,” she says. “We knew right then that we were going to develop more trust about reporting. Every risk manager knows that the amount of good you can do depends on how much people are willing to report issues.”

One strategy Crow used was to encourage nurses to buddy up during their shifts so they could watch each other for signs of fatigue and suggest a remedy. Pairing up makes them accountable to each other, she notes.

Risk managers must lead

Diamond says risk managers should assess the organization for fatigue-related risks such as under-staffing, consecutive shift work, and policies that encourage overtime. A fatigue management plan should include education of staff about the effects of fatigue and good sleep hygiene, as well as making it a responsibility for staff members to intervene when they notice a colleague suffering from effects of fatigue.

Research has demonstrated that specific strategies work to revive a fatigued employee, Diamond says. The other person should engage the fatigued employee in active conversations, lead him or her into physical activity, and encourage strategic caffeine intake. Caffeine typically takes about half an hour to kick in, so a cup of coffee might be best before a nap, not after. The hospital also should provide areas for nurses to nap, with ear plugs and eye masks, just as many facilities do for physicians, Diamond says. 

“It also is important to provide opportunities for staff to express concern about fatigue,” Diamond says. “Collect data on work hours, scheduling, absenteeism, workers’ comp, job satisfaction, and adverse events. Always analyze fatigue when evaluating adverse events.”

Boothman notes that the turnover rate can be a measure of how much fatigue is threatening patient safety. More than income, nurses tend to choose employment based on quality of life and satisfaction that they are helping their patients, he says. “Where people are asked to do too much with too little, you will see nurses moving in droves to other organizations,” he says. “That can be a major red flag, so the risk manager should always keep a finger on the pulse of the hospital’s nurse turnover rate. It’s the best indicator of how happy your nurses are, and fatigue has a big effect on job satisfaction.” 

Creative scheduling can greatly reduce nurse fatigue, says Lydia L. Forsythe, PhD, MA, MSN, RN, CNOR, an adjunct faculty member for the master of science in nursing (MSN) and doctor of nursing practice (DNP) programs at Kaplan University School of Nursing in Oklahoma City. Options include providing four-hour shifts, providing two-hour bonus shifts, and prohibiting 12-hour shifts or any back-to-back shifts.

“Hospitals get stuck in the traditional way of thinking about scheduling, and it takes a really tenacious person to advocate for something that might sound radical but actually works out better for both nurses and patients,” Forsythe says. “We also have to plan for the predictable spikes in patient population, like flu season. If you don’t schedule for that, you end up needing people to work overtime and more shifts.”







  • Richard C. Boothman, JD, Chief Risk Officer, Executive Director of Clinical Safety, University of Michigan Health System, Ann Arbor. Email:










  • Brandi Crow, BSN, RN, Clinical Analyst, MD Buyline, Dallas. Email:










  • Robin Diamond, MSN, JD, RN, Senior Vice President, Patient Safety and Risk Management, The Doctors Company, Napa, CA. Telephone: (707) 226-0291. Email:










  • Lydia L. Forsythe, PhD, MA, MSN, RN, CNOR, Adjunct Faculty Member, Kaplan University School of Nursing, Oklahoma City. Email:










  • Bette McNee, Health and Human Services Technical Specialist, The Graham Company, Philadelphia, PA. Email: