Action urged to fight healthcare worker fatigue

The link between healthcare worker fatigue and adverse events is well documented, prompting The Joint Commission to issue a new Sentinel Event Alert: Health care worker fatigue and patient safety. The alert urges greater attention to preventing fatigue among healthcare workers and suggests specific actions for organizations to mitigate the risks.

An article in The Joint Commission Journal on Quality and Patient Safety reported that nurses who work more than 12-hour shifts and residents working recurrent 24-hour shifts were involved in three times more fatigue-related preventable adverse events.1 In addition, healthcare professionals who work long hours are at greater risk of injuring themselves on the job. Some agency and part-time employees might come to your facility immediately after finishing a full shift at another facility.

"Healthcare is a round-the-clock job, and safety has to be the priority," says Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission. "The recommendations in this alert give healthcare organizations the strategies to help mitigate the risks of fatigue that result from extended work hours, and, thereby, reduce the likelihood that fatigue will contribute to preventable patient harm."

The alert addresses the effects and risks of an extended work day and of cumulative days of extended work hours. The Joint Commission alert recommends that healthcare organizations:

  • Assess fatigue-related risks such as off-shift hours, consecutive shift work, and staffing levels.
  • Examine processes when patients are handed off or transitioned from one caregiver to another, a time of risk that is compounded by fatigue.
  • Seek staff input on how to design work schedules that minimize the potential for fatigue and provide opportunities for staff to express concerns about fatigue.
  • Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue such as engaging in conversation, physical activity, strategic caffeine consumption, and short naps.
  • Educate staff about good sleep habits and the effects of fatigue on patient safety.

The Joint Commission also suggests that healthcare organizations encourage teamwork as a strategy to support staff who work extended work shifts or hours. For example, use a system of independent second checks for critical tasks or complex patients. Also, organizations should consider fatigue as a potentially contributing factor when reviewing all adverse events, They should educate employees on the importance of good sleep habits, including ensuring their rest environment is conducive to sleeping.

The warning about healthcare worker fatigue is available at It is one of a series of alerts issued by the Joint Commission. Previous alerts have addressed healthcare technology, wrong-site surgery, and others. Past issues of Sentinel Event Alert can be found on the Joint Commission web site at


  1. Lockley SW, Barger LK, Ayan NT, et al: Effects of health care provider work hours and sleep deprivation on safety and performance. Joint Comm J Qual Pat Safety 2007; 33:7-18.