By Coverys Risk Management

Healthcare organizations providing 24-hour care have always faced staffing challenges. 

But, with emerging trends such as nursing shortages and shorter lengths of hospital stays, nurses’ shifts have increased well beyond the traditional eight-hours. In many facilities it is common practice to have 10- to 12-hour shifts, with some nurses reporting even longer times at work — nearly 24 consecutive hours.

Not surprisingly, these extended work hours bring up concerns of worker fatigue and its effects on patient safety. From the Accreditation Council for Graduate Medical Education (ACGME) to the Joint Commission, strong recommendations have been made to reduce the number of on-the-job hours for healthcare providers, in order to help prevent adverse patient outcomes resulting from a lack of sufficient rest.

Strategies for Reducing Provider Fatigue
Understandably, the demands of patient care don’t always allow for scheduled rest. In those situations, it may be helpful to follow the guidelines published by the National Highway Traffic Safety Administration when establishing organizational policies to help reduce provider fatigue on the job:
  • Recognize that the urge to sleep is very strong between 2:00 a.m. and 9:00 a.m., and especially between 3:00 a.m. and 5:00 a.m. Avoid assigning unnecessary work at that time.
  • Schedule backup workers during times that providers are most likely to be fatigued.
  • Create an area where healthcare workers can rest when appropriate. The sleep environment should be quiet and dark. It should have adequate ventilation and a comfortable temperature to allow daytime sleep.
  • Understand that behavioral changes, such as irritability, may indicate dangerous levels of fatigue, and respond accordingly.
  • Educate healthcare workers with respect to healthy sleep habits. These include going to sleep immediately after working a night shift to maximize sleep length, and using naps strategically (e.g. a two-hour nap before a night shift will help prevent sleepiness. When a two-hour nap isn’t possible, naps should be less than 45 minutes, to avoid sleeping so deeply that it makes alertness more difficult to achieve).

In addition to the aforementioned strategies for addressing healthcare worker fatigue, the Joint Commission suggests several evidence-based actions that can also reduce the risks due to fatigue while protecting patients from preventable harm:
  • Assess your organization for fatigue-related risks.
  • Assess your organization’s hand-off processes and procedures to ensure patients are adequately protected.
  • Ask staff members for input on designing work schedules to minimize fatigue potential.
  • Provide opportunities for staff members to express their concerns about fatigue.
  • Encourage staff members who work extended work shifts or hours to use teamwork as a supportive strategy and to protect patients from potential harm.
  • Consider fatigue as a potentially contributing factor when reviewing all adverse events.

Fatigue Risk Management System
As suggested by the Joint Commission, once a corporate commitment is made to reduce healthcare worker fatigue and thus make it a safer environment for patients, a fatigue risk management system (FRMS) should be developed. 

The key characteristics of an FRMS include being science-based, data-driven, cooperative, fully implemented, integrated, continuously improved, budgeted, and owned. Your FRMS should address six key dimensions to be effective:
  1. Workload-Staffing Balance
  2. Shift or Duty-Rest Scheduling
  3. Employee Fatigue Training & Sleep Disorder Management
  4. Work Environment Design
  5. Alertness Monitoring & Fitness for Duty
  6. Processes for Monitoring & Evaluating Fatigue-Related Events

While developing an FRMS may appear to be very challenging at the outset, a careful review of your organization’s current policies, procedures, and practices may actually reveal that portions of the FRMS are already in place.  

In the end, preventing healthcare worker fatigue is about preventing human error that puts patients at risk. It takes a commitment from employees at all levels to achieve the kind of alertness that keeps patients safe. Administrators should contribute to the process by reviewing their organizations’ policies, procedures, practices, and cultures with respect to overtime practices, shift-work, patient hand-offs, the work environment, and employee rest periods. Likewise, employees should be encouraged to do their part by evaluating the effects that fatigue has on their professional and personal lives, and determining what they can do to support restful, adequate, and uninterrupted sleep on a daily basis. Making the time to give the body what it needs is critical not just to the individual healthcare worker’s own health and comfort, but to the organization as a whole and to the patients with whose care we are all entrusted. 


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No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.