ED Accreditation Update

Sentinel Alert sounds the alarm on worker fatigue; hospitals urged to mitigate risks

Experts: Keep an eye on worker shifts, limit distractions during handoffs

With hospitals open for business on a 24/7 basis, it can be difficult for physicians, nurses, and allied professionals to get adequate rest as well sufficient time between scheduled shifts. And experts say these are the types of issues that lead to worker fatigue, which not only heightens the risk for adverse events, but also creates safety challenges for the hospital workers themselves. For all these reasons, the Joint Commission, based in Oakbrook Terrace, IL, has issued a Sentinel Alert, urging health care organizations to take steps to improve the workplace policies and procedures that lead to worker fatigue.

One of the most effective ways that ED managers can combat fatigue is to keep an eye on the shifts that people are working and, in particular, to make sure that people are actually leaving their jobs when their shifts are concluded, explains Ann Rogers, PhD, RN, FAAN, a sleep expert at Emory University's School of Nursing in Atlanta, GA. "Our data suggest that very few nurses leave work on time. They are working almost an hour beyond their shifts so that a 12-and-a-half-hour shift becomes a 13-and-a-half-hour shift," she says.

Rogers also emphasizes that no one should ever be working more than three consecutive days of 12-hour shifts, especially if these shifts are during the evening and nighttime hours, and she says that double shifts should be banished. "We have seen people scheduled for 20-hour shifts and longer," says Rogers. She adds that the overall tally of hours is important as well. "We have seen that when nurses work over 40 hours per week, the risk of them making an error goes up."

Reevaluate policies on strategic naps

When designing shifts, try to avoid start times between the hours of 2 a.m. and 5 a.m., and 2 p.m. and 5 p.m., because these hours are when the body is trying its hardest to sleep, explains Linda Scott, PhD, RN, NEA-BC, FAAN, professor and associate dean for graduate programs at Grand Valley State University's College of Nursing in Grand Rapids, MI. Scott has conducted research into worker fatigue in the health care environment. "When you think of people getting up at 2 or 3 o'clock in the morning when the drive to sleep is the strongest, they are at risk for a drowsy driving accident," she says. "When they get to work they are sluggish, so they struggle. And then they work an extended period of time, become fatigued, and then they have to drive home during another period of time when the drive to sleep is the strongest."

Another issue that managers need to consider is making sure that all staff members receive breaks during their shifts during which they are completely relieved from their work responsibilities, says Rogers. "Research has shown that breaks really do help, so whether you are talking about nurses, physicians, pharmacists, or allied health professionals, they really do need a lunch break, and they really do need 10-minute breaks every couple of hours because we just can't continue to concentrate at the highest level for 16 hours," she says.

For staff who work during the nighttime hours, a strategic nap is one of the most protective things they can do to prevent fatigue and ensure that they will be able to drive home safely, says Rogers. However, she says that many organizations actually prohibit such naps. In fact, it can be grounds for firing at many institutions, says Rogers, noting that hospitals and other health care entities that have such policies should reevaluate them with worker fatigue and patient safety in mind.

Scrutinize handoff procedures

The Joint Commission urges hospitals to take a close look at their handoff procedures, when one caregiver transfers a patient's care to another caregiver, because these transition periods are a "time of risk that is compounded by fatigue." However, too often these critical handoff periods are given as a reason to extend a resident's work hours, explains Christopher Landrigan, MD, MPH, the director of the Sleep and Patient Safety Program at Harvard Medical School in Boston, MA.

"The reason for this is the notion that if we are going to reduce the duration of resident work hours, then inevitably what is going to happen is that you are going to have more transitions between physicians that are changing shifts," says Landrigan, noting that people question whether reducing work hours is really safer if that leads to more transitions between caregivers, which are hazardous themselves. "We know that there are many, many examples of serious medical errors that arise as a consequence of faulty handoffs, but it is not at all clear that reducing hours all by itself inevitably leads to worse handoffs."

In fact, Landrigan says that multiple studies have demonstrated that when work hours are reduced, the care of patients becomes safer, despite the handoff problem. "That is because in most of these cases, the programs or institutions that have done a good job of designing new schedules and reducing work hours have been very conscientious about focusing on the handoff problem and making sure that they develop robust systems for transmitting information."

How should organizations evaluate handoffs in terms of safety? There are several elements to consider, says Landrigan. First, think about the environment in which the handoff takes place, he says.

"Very often in medical settings when patients are being handed off, it is in a busy ED or in a busy setting of another type where there are lots of interruptions; somebody is trying to hand off information and he is being distracted by phone calls, pagers, and other activities," explains Landrigan. "We know from the medical literature, as well as broader literature on this issue, that those kinds of chaotic environments are recipes for problems, so to the extent possible, find a protected space and a protected time frame where interruptions can be minimized."

Secondly, think about both the verbal handoff process and the written handoff process and try to optimize those, advises Landrigan. "Studies have demonstrated that when there is both a written and a verbal handoff, it is better than just having one or the other," he says. "And when both of those handoffs are structured and standardized, and some team training is done in a particular clinical environment to make sure that they are high quality, then the risk of handoff errors goes way down."

Landrigan acknowledges that it can be tough to invest in staffing and quality processes when the pressure is on to reduce costs, but he emphasizes that organizations need to remember that safer care is less expensive care. "Adverse events are very common and very expensive, so pretty much anything we can do to reduce adverse events, such as improving handoffs and reducing provider fatigue, has the potential to eliminate these adverse events and thereby reduce costs."


  • Christopher Landrigan, MD, MPH, Director, Sleep and Patient Safety Program, Harvard Medical School, Boston, MA. E-mail: clandrigan@rics.bwh.harvard.edu.
  • Ann Rogers, PhD, RN, FAAN, Professor, Emory University School of Nursing, Atlanta, GA. E-mail: ann.e.rogers@emory.edu.
  • Linda Scott, PhD, RN, NEA-BC, FAAN, Professor and Associate Dean, Graduate Programs, Grand Valley State University College of Nursing, Grand Rapids, MI. E-mail: scottl@gvsu.edu.