TJC gives wake-up call on fatigue risks

OSHA balks at adding enforcement

Healthcare facilities have been put on alert to recognize fatigue among workers as a risk to patient safety. But for now, facilities won't face any regulatory consequences for failing to address it.

The Occupational Safety and Health Administration (OSHA) denied a petition to regulate the duty hours of medical residents, noting that the Accreditation Council for Graduate Medical Education (ACGME) has adopted stricter duty hour limits. Instead, OSHA administrator David Michaels, MD, MPH, said the agency will develop guidance on "coping with the effects of fatigue and sleep deprivation."

A Sentinel Event Alert from The Joint Commission indicates that the accrediting body is concerned about the impact of fatigue on patient safety. But while the alert offers suggestions on fatigue management, it doesn't direct healthcare employers to limit shift length. "The purpose of the alert is really to educate and create awareness," says Ana Pujols McKee, MD, executive vice president and chief medical officer of The Joint Commission. Fatigue has not been widely addressed in healthcare facilities, she says.

The alert should begin a dialogue about fatigue, its impact, and ways to mitigate it, McKee says. "We ask organizations to conduct their own assessments and look at their adverse events and analyze trends and patterns where fatigue might have been [an issue]," she says. "I anticipate there will be more discussion, more information, and more opportunity to provide risk-reduction strategies."

Error rises with longer shifts

Long work hours and rotating shifts make physicians and nurses more prone to error. That fact is supported by a growing body of evidence, which is creating pressure for healthcare employers to limit shift length and overtime.

In 2004, an Institute of Medicine (IOM) panel recommended state rules to restrict nurses to shifts of no more than 12 hours in a 24-hour period and a workweek of no more than 60 hours in seven days.superscript1 While some states prohibit mandatory overtime for nurses, there are no limits on shift length or voluntary overtime.

Yet studies continue to show an impact on patient safety. In one study, 393 nurses kept track of their work hours and errors or near-errors for four weeks. All of them worked at least one day of overtime, and about one-third worked overtime every day they worked. More than a quarter (28.7%) reported working mandatory overtime at least once during that timeframe.superscript2

The number of errors and near-errors rose with length of shift and was significantly higher for nurses working more than 40 hours or more than 50 hours a week.

Lead author Ann E. Rogers, PhD, RN, FAAN, Edith F. Honeycutt Chair in Nursing and director of Graduate Studies at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, says, "When a nurse worked 12.5 hours or longer, the nurse was three times more likely to report making an error than when they worked a shorter shift. We also found that nurses invariably worked much longer than scheduled. They got out on time once every five shifts they worked."

The Joint Commission advises healthcare providers to involve employees in designing work schedules that minimize fatigue.

For now, healthcare employers are being urged to monitor themselves. Some chief nursing officers have banned double shifts (16 hours), says Rogers. Chief nursing officers also may monitor timecards to make sure nurses aren't working excessive amounts of overtime, she says.


  1. Page A, ed, Committee on Work Environment for Nurses and Patient Safety. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.
  2. Rogers AE, Hwang WT, Scott LD, et al. The working hours of hospital staff nurses and patient safety. Health Affairs 2004: 23:202-212.