THE FATIGUE FACTOR IN
PATIENT SAFETY
BONNIE DEVEAU, RN, MSN, MA, NE -BC
VICE PRESIDENT, QUALITY & PATIENT SAFETY
GOODALL HOSPITAL
Goals and Objectives
◦ 1. Identify risks associated with healthcare worker fatigue at the
patient and staff level
◦ 2. Describe contributing factors to healthcare worker fatigue
◦ 3. Critique evidence-based strategies effective to combat
healthcare worker fatigue
◦ 4. Apply evidence-based strategies to educate staff regarding the
effects of fatigue on patient and staff safety
◦ 5. Analyze how evidence-based strategies could be applied within
the facility
WHAT KEEPS US UP AT
NIGHT?
WE CAN PROBABLY COME UP WITH A MILLION CAUSES!
Building a Safer Healthcare System
◦ Where did this concern come from:
◦ Government & regulatory agencies, the public, and healthcare leaders
are looking to healthcare professionals to focus attention on safety
◦ To Err is Human: Links medical errors to the human factor recognizing
fatigue as an underlying cause of medical errors
◦ The National Center of Sleep Disorders confirms the scientific
evidence that chronic sleep deprivation leads to chronic disease, injury
disability and premature death. This evidence has been well
documented since the 1980’s and will be the basis for this
presentation and discussion today
Background and Significance of the Issue
Sleep duration and quality and its importance:
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Studied by National Institutes of Health (NIH)
National Centers for Sleep Disorders
Centers for Disease Control (CDC)
National Institute of Occupational Health & Safety (NIOSH).
The Joint Commission’s Sentinel Event Alert of December 2011:
◦ Spotlights fatigue as a result of:
◦ Shift work
◦ Shift length
◦ Work schedules
National Efforts
to Reduce
Medical Errors
The driving force behind quality
initiatives are in the statistics:
◦ Medical Errors in a 2012 US News & World
Reports: Medical Errors harm a huge number of
patients
◦ In 2010 CMS found 134,000 Medicare
beneficiaries suffered an adverse event that was
either clearly or likely preventable
◦ A North Carolina study conducted over 5 years
reported 25% of all admissions received medical
care that resulted in some form of harm – that is
1 in 4 patients!
◦ Sentinel Event Data from Joint Commission over
a 10 year period (1996 to 2006) 3,881 sentinel
events reported to TJC, by type
The Problem
Healthcare is a 24 hour
operation
• Consists of extended work
hours
and shift work
Shift work is essential
component
• Leads to healthcare worker
fatigue and medical errors
Medical Errors
Financial
burden: Patient
and healthcare
system
Emotional
Burden: Patient
and facility
Results:
Mandatory
quality
initiatives and
regulations
Healthcare Industry Transformation
Cost
Quality
The Physiology of Sleep
ESSENTIAL TO UNDERSTAND THE CORRELATION BETWEEN FATIGUE
AND MEDICAL ERRORS
Sleep Research
◦National Institute of Health started to research sleep and
its effects in the 1970’s
◦ Defined sleep and its relationship to the human “biological clock” through
the use of EEG
◦ The human brain has a circadian clock (24 hour duration) that controls the
timing, duration and stages of sleep
◦ Sleep is responsible for the optimal development and operation of the brain
and therefore CENTRAL to SLEEP!
◦ Sleep and Wakefulness = The sleep cycle is a series of chemical and electrical
activities stimulated by daylight and darkness
WHAT IS SLEEP?
A result of highly complex network of central
neurons that utilize neurotransmitters
(chemicals) to communicate important messages
from the brain to the rest of the body.
Neurotransmitters affect mood, sleep patterns,
concentration ability and body weight.
Commonly known neurotransmitters are:
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Histamine
Acetylcholine
Dopamine
Norepinephrine
Serotonin
Melatonin
Stages of Sleep
1.
2.
3.
4.
5.
Brain waves start to slow
Brain waves slow even more, eye
movements stop, HR & RR rates slow
Brain less responsive (when awoken in
this stage a person is groggy and has
poor memory)
Restorative and renewal stage –
promotes muscle and tissue growth
REM sleep - muscles are paralyzed
(prevents acting out dreams) & frontal
lobe activity is depressed. Someone
awakened in this stage is moody
/irritable
Alcohol Consumption
Caffeine Consumption
Smoking
What Affects
Neurotransmitters?
Stress
Poor Diet
The startling statistic:
Prescription / Recreational Drugs
86% of Americans have
suboptimal neurotransmitter
levels !
Sleep Deprivation
Humans were meant to be
awake during the daytime and
asleep during the nighttime
hours.
Aging Process
◦ Erratic Sleep Schedules
◦ Work schedules
◦ Social Media – living in a 24 hour society
◦ Bladder control issues
◦ Menopause: Hot flashes /night sweats
The Value of Sleep
High quality sleep is essential to good health and future
well-being
Eight (8) hours of sleep is defined as the optimal benchmark
Sleep patterns change throughout the human lifecycle
We are often forfeiting sleep for other activities
How did we become a 24-hour Society
◦ The industrial revolution redefined the
work environment and hours of operations
to 24 hours a day
◦ Healthcare has always been 24 hours but:
◦ Technology is now a major component
◦ Patients are sicker / higher acuity
◦ Shift work activity can be very busy
◦ Our ever so “social society”
Where is sleep on your list of daily
priorities?
The Influence of Nursing Shortages
◦ Nursing shortages and long work hours can be traced back as far as the 19th
century during the Civil War
◦ Nursing education programs had students working 12 hour shifts however,
they had very strict rules for monitoring time off and sleep periods
◦ The 1980’s rolled out the “Baylor Program” to draw nurses back to work and
alleviate a nursing shortage
◦ The Baylor program was the “band aid” on the proverbial Nursing Shortage
“hemorrhage”
◦ The Baylor Program consisted of 12 hour shifts over a full weekend with full pay and benefits
◦ The Baylor Program was eventually eliminated due to costs - but the 12 hour shifts remained
◦ Today – the norm is 12 hour shifts and the preference of staff (reduced days at work)
Costs and Benefits of the Baylor Program
Costs
Benefits
1.
Increased the level of staffing needed on a
unit
1.
Provided instantaneous resolution to the
nursing shortage issue in the 1980’s
2.
Cost more money to administer this
program
2.
Acted as not only a recruitment tool but a
retention strategy as well
3.
12-hour shifts were starting to be a
struggle for the Baby Boomer population
3.
Full-time staff who worked 8 hour shifts
worked Monday though Friday
4.
12-hour shifts were identified as a desire
by non-weekend staff to decrease their
time at work; leaving the nurse to have
more free time
4.
Weekend staffing was no longer the
burden it had been in the past
The Aging Nurse: What are the
Challenges
The nurse may be coping with the following challenges:
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Physical and mental health changes
Decreased aerobic ability
Decreased muscle strength and endurance
Decreased reaction time
Decreased acuity with vision and hearing
Thermoregulation changes (hot flashes / night sweats)
Increased sleep disturbances
Changes in bladder control
Chronic illness / medications
Part of the “sandwich” generation
A Snapshot of the Maine Nursing
Workforce
Average age of RN’s:
50.6 versus 47 nationwide
Average Employed RN:
49.4 (48% are over 51)
Work Life:
57% of those > 51 years plans to work 5 more years
National Study in 2011: RN’s in their 4th decade of work tend to exit acute care settings
In 2000:
The RN vacancy rate was 12%
In 2008:
RN’s returned to the workforce or delayed retirement due to the
economic downturn
In 2020:
The RN vacancy rate is expected to be 31%
Working Shift Work
Disrupts
Circadian Cycle
Disrupts Family /
Social Life
Disrupts the
Quality and
Quantity of Sleep
Leads to Sleep
Loss and Sleep
Disturbance
Chronic Sleep Deprivation
Increases Risks For:
◦ Cardiovascular disease
◦ Cerebrovascular disease (CVA)
◦ Cancer: Breast, colorectal, and
prostate
◦ Obesity
◦ Diabetes
◦ GI Disturbances
◦ Memory Impairment
◦ Social / relationship issues
◦ Trauma – motor vehicle accidents
Performance Related Issues:
◦ Impaired job performance
◦ Flawed hand-offs
◦ Lack of teamwork
◦ Decreased employee morale
◦ Increased risks for errors
◦ Increased risk for work-related
injuries and workers’ compensation
costs (needlesticks / sprains/ strains)
Sleep Deprivation
17 continuous hours of work = A
Blood Alcohol level of 0.05%
24 continuous hours of work = A
Blood Alcohol level of 0.10% ( defined
as legally drunk)
Intoxication
How Prevalent is Fatigue in the US
70% of Teens sleep < 8-9 hours / day (as recommended)
◦ Sleep deprived teens are at risk for suicide, obesity, depression, mood problems, low grades and
delinquent behavior
70 % of adults report insufficient sleep monthly
◦ 11% of this 70% report insufficient sleep daily
65% report having sleep problems
◦ Either falling asleep or staying asleep
◦ Waking feeling drowsy
20% of all serious motor vehicle accidents are attributed to drowsy driving / sleep deprivation
Restriction on Medical Students /
Residents
The ACGME instituted changes in resident / medical school student maximum hours.
Healthcare’s first and only attempt at addressing fatigue in 2003.
 Intermediate-level residents must have at least 14 hours free of duty after 24 hours of in-house duty
 Residents must not be scheduled for more than six consecutive nights of night float
Test Case:
2005 A lawsuit was filed against a medical center whose resident fell asleep at the wheel on
their way home from work claiming liability for injuries sustained. The case was not upheld but it
was a case that could have merit in the future.
The aviation industry has scoffed at the new rules as being ineffective and not nearly strict
enough to impact patient safety.
The effects of 1 hour loss of sleep per
night
Altered concentration
Medication calculation/critical reasoning
Slowed reaction time
Codes and RRT’s/urgency to communicate information
Reduced problem solving ability
Patient Assessment
Lapses in attention and memory
Forgetting to follow through on a request / order
Reduced motivation
Absenteeism/apathy
Irritability and moodiness
Ability to get along with coworkers / Lack of Teamwork
Decreased ability to notice subtle changes
Accurate and ongoing Telemetry or monitoring data
Slowed information processing
Alarm Fatigue
Difficulty dealing with unexpected situations
Patient Satisfaction / Patient Complaints
Indifference and loss of empathy
Burnout
Communication difficulties
Shift report / Patient Hand-offs
How to Combat Fatigue?
 Keep consecutive night shifts to a minimum
 Avoid quick shift changes
 Plan some free weekends
 Avoid several days of work followed by 4-7 days off “mini-vacations”
 Keep long work shifts and overtime to a minimum
 Examine start and end times of shifts
 Keep schedule regular and predictable
 Examine rest breaks at work
 Make sleep a priority
Strategies to Reduce or
Minimize Patient Harm
YOUR ORGANIZATIONAL NEXT STEPS
How Can You Affect Change?
Assess the organization for fatigue-related risks:
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Evaluate staff schedules for consecutive shifts (particularly night shit schedules)
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Review organizational staffing policies
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Assess overtime needs / use
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Are the managers aware if staff is working per diem in other organizations
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Assess the organization’s hand-off process – are they effective
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Are staff self-scheduling or have input to their schedules
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Assess the multigenerational composition of your nursing staff
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Assess if an error or event could have been caused from fatigue
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Assess when meetings are scheduled
How Can You Affect Change?
Create and Implement a Fatigue Management Plan:
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Incorporate scientific strategies for fighting fatigue:
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Strategic Caffeine Consumption (but not near bedtime)
Physical Activity
Active Conversations
Importance of Meal and Rest Breaks
Teamwork
Strategic Naps !
How Can You Affect Change?
Educate:
 Senior Leadership
 Management Staff
 Direct Care Staff (include medical staff)
Share your Assessment Findings
Promote an Action Plan
What I Discovered
Nearly all nursing staff who worked in direct care roles worked 12 hour shifts
Most of the day staff worked 2 consecutive shifts with a day off
Most of the night staff clustered their shifts to have a large number of days off
Overtime was used frequently to fill vacancies and sick calls
More than 24 RN’s worked per diem or fulltime in another organization
Staffing and overtime policies existed but were not proactive to promote safety limitations
Hand-offs were an opportunity for improvement
Teamwork was not well developed
STAFF SURVEY
Question
Yes
No
Do you average between 6.5
and 8 hours a sleep a day?
60
41
Do you feel fatigued
regularly at work?
45
56
Do you think fatigue could
contribute to a patient error
or employee injury?
94
7
Do you know or see any
fatigue related issues in your
department?
47
54
Would you be interested in
knowing more about
55
45
healthcare worker fatigue?
Note: 1 survey had no response on this
question
SHIFT WORKER HELPFUL HINTS
Food, Drink, and Sedating and Stimulating Medications
 Avoid food, alcohol, and drinks that are high in caffeine at least six hours before going to bed
 Stop smoking or avoid nicotine before going to bed
 Follow a diet and activity routine to maintain an ideal body weight. If overweight or obese,
consider a plan to lose weight
 Avoid eating a heavy meal three to four hours before going to bed; eat the biggest meal of the
day after waking
 Eat high-protein, light meals while at work and before going to bed
 Limit fluid intake to 8 oz. just before going to bed
 If you awaken during the day, get up to use the bathroom and, if hungry, eat a light protein
snack in a dim or dark environment, then return to bed.
 Discuss the use of over-the-counter melatonin, sleep medications and/or herbal remedies with
a primary care provider
SHIFT WORKER HELPFUL HINTS
Bedroom Environment
 Design the bedroom to make it suitable for day sleep
 Maintain the room’s temperature from 65°F–70°F
 Wear light bedclothes and use light bedcovers
 Cover all windows with room-darkening or blackout shades
 Hide crystal clock displays
 Reduce all potential disturbing noises (e.g., telephone, clock noises, and pets) and wear
earplugs or use white noise to block out environmental noises
 Do not bring worries or stress to bed
 Develop a habit of a bedtime relaxation period before attempting to go to sleep; learn how to
relax the body and mind before attempting to sleep
 Select a relaxation method to use within an hour of going to bed (e.g., deep breathing, warm
bath / shower, reading)
SHIFT WORKER HELPFUL HINTS
Exercise
 Establish a 30-minute period of time or longer for physical activity three to
seven days per week after waking. Stop exercising three hours before bedtime
Family and Social Issues
 Hang a sign on the bedroom door noting “day sleeper” as a reminder to family
 Discuss individual needs for sleep with family and friends
 Choose social activities wisely (i.e., avoid activities at the time sleep typically is
scheduled)
SHIFT WORKER HELPFUL HINTS
Recommendations for Rotating Shift Workers
 Maintain consistent bedtimes and wake-up times on the shift that most commonly is worked
 Use the anchor sleep method during rotations to other shifts
 Work a maximum of three consecutive shifts per week when on an alternate shift (days)
 Be sure to have two days off in a row when working an alternate shift
 Explore reducing shift-work rotations; attempt to hire more permanent night-shift workers
 If unable to hire an adequate number of permanent night-shift workers, use forward rotation
(i.e., day, evening, and night) at two-week intervals.
 Regular rotating shift workers should modify their lifestyles to allow for participation in social
activities within the limitations of the work schedule (e.g., join a health club that is open all day
instead of joining a group that meets at a specific time)
 While at work, take regular rest breaks and power naps (if facilities are available and permitted
by employer)
Summary
 12 hour shifts have been identified as detrimental to Nurses and Patients
 Shift work is not healthy = but night shift staff can adapt with a lot of focused attention and
work
 Humans were meant to sleep at night and be awake during the day
 The human body has not adapted to the 24 hour society we live in
 The research links poor sleep and chronic fatigue with physical and mental health disorders
 The nursing profession has yet to take any proactive steps to implement strategies to reduce
fatigue
 Staff education is needed
 Patients and nurses are not safe!
Would we all like to remember what is was like to
“Sleep Like a Baby”?
Ruby
DISCUSSION
WHAT’S NEXT ?