Shift Work and Its Impact on Medical Error

Consequence of Human Fatigue

• Both a physical and mental price is bestowed upon the worker who is not able to restore or receive enough rest between shifts.

• Within this context is the connection and possible contribution with effects toward making medical errors

• Support the worker - who is most at risk and often blamed for a systems error

We Know • Human beings are designed to perform at

peak levels during the day as opposed to night.

• Our bodies design or daily biological functions are what scientists call “circadian rhythms.”

• Our bodies actually want us to slow down at night to restore and rejuvenate ourselves

Definition of Work Shifts• Normal work shift: • Daytime work period ≤ 8 consecutive hours• 5 days per week• At least an 8-hour rest between shifts• Note there is no OSHA standard

Extended or Unusual Work shifts• Anything else –• Work shifts day, evening, night• Extended or unusual shifts• Consecutive unusual shifts• Regular, rotating , predictable ,unpredictable• Voluntary or mandatory• Planned or unplanned• Split Shifts• Overtime

Agency For HealthCare Research And Quality

• In an effort to reduce errors due to fatigue hours of work are standard in some non-medical fields

• Truck drivers are typically allowed to work no more than 10 hours at a time & no more than 60 hours in one week.

• Airline pilots and air traffic controllers work regulated hours

Agency For HealthCare Research And Quality

• Most healthcare personnel are not subject to work-hour standards

• Many physicians-in-training are, either by statutory regulations or by being in an accredited training program

• *Ashish K. Jha, M.D.; Bradford W. Duncan, M.D.; David W. Bates, M.D., M.Sc. Fatigue, Sleepiness and Medical Errors

DEFINITION OF HUMAN FATIGUEMartin Moore-Ede, M.D., Ph.D.

• Fatigue impairment of mental and physical function manifested by a cluster of debilitating symptoms

• Including excessive sleepiness, reduced physical and mental performance ability, depressed mood, loss of motivation

• http://www.circadian.com/index.php?option=com_content&view=article&id=162&Itemid=140

Causes of Fatigue• Extended work hours• Shift work • International travel • Sleep disorders • Medications • Medical conditions • Drugs and alcohol• Insufficient sleep

Heavy Stressful Physical or Mental Exertion:

• Fatigue occurs with extended hours of work and heavy muscular activity (e.g. lumberjack, or marathon runner), continued stress or danger (e.g. combat fatigue) or intense mental exertion (student taking LSAT examinations)

• Fatigue occurs either during the task or as a rebound effect after the task, in proportion to the relative fitness (and/or prior training) of the individual.

Sleep Deprivation

• Fatigue is the result of an extended time awake (acute sleep deprivation)

• Reduced time asleep• Disrupted or poor quality sleep (partial sleep

deprivation) or no sleep

Chronic Sleep Deprivation

• The cumulative effect of multiple days with shortened or disrupted sleep can lead to what is referred to as chronic sleep deprivation

• This can occur in jobs with extended work hours or with night shift work

Illness or disease:• Fatigue common in many diseases and

illnesses (ranging from flu to cancer)• Can occur as a direct result of the metabolic

or other systemic patho physiological disturbances of that disease

• Secondary consequence of sleep disturbances caused by other symptoms such as pain, nausea etc.

• The primary presenting complaint (e.g. chronic fatigue syndrome).

Sleep Disorders• Obstructive sleep apnea, restless legs

syndrome• Narcolepsy can be found with 85 other

different sleep disorders listed in the International Classification of Sleep Disorders

Therapeutic Side-Effect

• Fatigue is a commonly listed side-effect of prescription or pharmacological drugs

• Over-the counter medications • May occur as the result of other therapeutic

interventions (e.g. surgical procedure)

Stimulant Drug Usage

• Fatigue often occurs as a person rebounds after the initial euphoria or "high" induced by illegal or prescription stimulant pharmacological substances

Alertness and Safety• Extremely fatigued individuals experience

what is called “automatic Behavior Syndrome” (ABS).

• Low level of alertness that precedes nodding off

• Also known as “autopilot” characterized by the inability to react effectively to change

Autopilot

• People are present with eyes wide open set in a blank stare

• Brain wave activity is similar to that of being asleep.

• During this lower mental state, individuals can perform routine tasks for 20 to 30 minutes or more without active awareness.

Accountability and the Reality of the Human Condition

• Errors of commission administering the wrong medication to a patient because it looks or sounds like another. This type of error happens 1 out of 300 times

• Errors of omission is the unintentional act of forgetting to do something correctly like I out of 100 times

* Frankel Allan M.D. et all; The Essential Guide for Patient Safety Officers

Increased Medical Error • Survey of Medical Residents in Relation to

Medical Errors found• Probability of reporting at least one fatigue

related clinically significant medical error increased by a factor of 7 during the months residents worked five or more overnight shifts in comparison to nights they worked no overnight shifts. (Barger L.K., et al)

Increased Medical Error cont’d• Physicians in training scheduled for 24 hours shifts incur a greater risk for injuryto their patients, others and themselves• They make 36% more serious medical

errors than those who work 15 consecutive hours

Increased Medical Error cont’d

• Make five times as many serious diagnostic errors

• Experience twice as many on the job attention failures at night

• Suffer 61% more needlestick and other sharp injuries after 20 hours of work

Canadian Centre for OHS • Identified effects of fatigue as reduced: Ability to make decisions

Communication skillsProductivity & performance Attention & vigilance Ability to handle stress on the jobReaction time in speed & thought

• Failure to respond to changes in environment • Studies show similar to being legally drunk or a

sleep

Canadian Centre for OHS • Failure to respond appropriately to

information provided• Unable to stay awake • Increased forgetfulness • Medical costs • Increased tendency for risk-taking • Accident rates

Research from the University of British Columbia

• Data collected from 30,000 Canadians • Compared results between workers involved in

different types of shift work from 1996-2006.• Dramatic increase in number of Canadians

working non-standard hours • Canadians working night and rotating shifts are

almost twice as likely to be injured on the job

Research from the University of British Columbia

• Women found to be at a greater risk for workplace injury associated with shift work

• More pronounced for women working rotating shifts

• # of women working rotating & night shifts increased by 95 per cent during the study period, primarily in the health care sector

Who is at Risk • More than 20% of the U.S.

workforce is involved in shift work

• Nearly 30% of the full time employed nurses participate in shift work. (Barger L.K., et al.: Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoSMed3:e487, 2006)

Epidemic of Fatigue among Canadian workers

• increased absenteeism• increased turnover • decreased productivity• increased drug use • increased errors and accidents • higher group insurance premiums

Epidemic of Fatigue Among Canadian Workers

• According to a recent Angus Reid survey, more then 50% Canadians claimed not enough rest & suffer periods of low energy at work; nearly as many state it adversely affects their job performance.

• A worker accepted a job with a five hour commute -after eight consecutive shifts, his car crashed after he fell asleep while driving

• Sleeping On the Job: Compliance Solutions Canada http://www.compliancesolutionscanada.com/articles/pub_lib45.asp

Overtime • Overtime – hours on the job beyond the

scheduled time for a individuals’ shift and/or work week.

• Overtime - used in health care to meet staffing needs due to employee shortage and/or patient influxes.

• It is well documented that overtime has been a major management tool to ensure patient coverage (Olds, Daniel M.; Clark, Sean P. & Bloomberg, Lawrence s.; 2010)

Overtime • Review of NY State data, 1995 to 2000 found

an average of 4.5 % total paid hours worked by registered nurses (RNs) were paid over time. (Berney & Needleman& Kover, 2005)

• 1995 to 2002 paid overtime increased from 3.9% to 5.9% total hours & mean overtime rose from 0.23 hrs per patient to .39hours per patient. (Berney & Needleman, 2005)

What Have We Found

• We can protect patients & help reduce costs by managing banning mandatory overtime.

• Overtime associated with increased risk of catheter-related urinary tract infections and

bedsores, both preventable medical complications.

* (Patricia Stone W, Ph.D, et al., June 2007)

What Have We Found• Stopping Mandatory Overtime is Good for

Patients• Nurses working overtime are 3x more likely

to make errors (Rogers, Ann E, et al., July/ Aug 2004)

• An administrator from the Robert Wood Johnson University Hospital in New Brunswick said "By not mandating overtime, nurses are better rested, they can think more clearly and patient outcomes improve as a result.“(Fitzgerald, Beth. Feb 11, 2012)

What Have We Found

• Catheter-associated urinary tract infections incur an average cost of $44,043 per hospitalization

• Bedsores carry an average cost of $43,180 per hospitalization

*New Medicare Payment Rules: Danger or Opportunity for Nursing? Kurtzman, American Journal of Nursing, 2008.

Possible Solutions• Mandatory overtime has been regulated in

Sixteen states to prevent nurses from working long hours

• Regulations limit nurse mandatory work in two ways

• #1 Nurses can refuse to work out side their scheduled hours (other than a disaster)

• #2 Limit total work hours within a specific time frame (no more than 12 hrs in 24 hrs)

What We Can Do • Educate health care workers about the

consequences of extended work hours.• Personal health outcomes, adverse events

and patient safety • Identify state mandatory nurse overtime

regulations & advocate for implementation in the workplace

• Not all hospitals conforming to regulations • Have a plan of advocacy when nurses report

facility non compliance & violate regulations

More Evidence on The Effects of Shift Work

• Probability of health care error is 3x greater with 12.5 hours work

• Recent studies found long hours significantly related to patient mortality

• Long work hours, unsupportive practice environments, excessive physical & psychological demands contribute to nursing shortages. (Bae,Heui-Sung, 2012)

Sentinel Event Alert #48• Health care worker fatigue and patient

safety:• The purpose of this Sentinel Event Alert is to

address the effects and risks of an extended work day and of cumulative days of extended work hours.

• Including but not limited to insufficient staffing and excessive workloads

Findings from a Groundbreaking Study

• 2004 study of 393 nurses over more than 5,300 shifts – the first in a series of studies of nurse fatigue and patient safety

• Nurses who work shifts of 12.5 hours or longer are three times more likely to make an error in patient care.

The Impact of Fatigue• lapses in attention & inability to stay focused • reduced motivation • compromised problem solving • confusion • irritability • memory lapses

Impact of Fatigue

• impaired communication • slowed or faulty information processing and

judgment • diminished reaction time • indifference and loss of empathy

Scientific Strategies to Fight Fatigue • Assessment of Organization includes;

Review staffing - hand off process & procedures that need to protect patients

• Policies to ensure extended work shifts & Hours• Off shift & consecutive shift work

• Obtain staff input designing work schedules• Create & implement a management fatigue

plan

Scientific Strategies to Fight Fatigue• conversation with others (not just

listening & nodding)• Physical activity such as stretching &

walking • Strategic caffeine consumption avoid

when alert & near bedtime.• Short naps less than 45 minutes

Scientific Strategies to Fight Fatigue

• Educate staff about sleep hygiene • Includes getting enough sleep - naps Pre sleep routine such as yoga or reading No stimulating food or alcohol that may

impact sleep

References

• Agency for Healthcare Research and Quality Chapter 46. Fatigue, Sleepiness, and Medical Errors Ashish K. Jha, M.D., University of California, San Francisco School of Medicine

Bradford W. Duncan, M.D. Stanford University School of Medicine

David W. Bates, M.D., M.Sc. Harvard Medical School

References• Barger L.K., et al.: Impact of extended-

duration shifts on medical errors, adverse events, and attentional failures. PLoSMed3:e487, 2006)

• Bae,Heui-Sung, “Nurse Overtime, Working Conditions, and the presence of Mandatory Nurse Overtime”. Workplace Health & Safety . Vol.60, NO.5, 2012

References• Berney B, Needleman J, Kovner C. Factors

influencing the use of Registered Nurse overtime in hospitals, 1995 -2000. Journal of Nursing Scholarship 2005;37(2):87-100 [Pubmed:15960061]

• Berney B, Needleman J. Trends in nurse overtime, 1995-2002. Policy, Politics and Nursing Practice 2005;6(3):183 -190

References• Stone Patricia W. Ph.D, et al., Nurse Working

Conditions and Patient Safety Outcomes, Medical Care, 45(6); 571-578, June 2007

• Kurtzman; New Medicare Payment Rules: Danger or Opportunity for Nursing?, American Journal of Nursing, 2008.

• Rudik , Isaac; “Sleeping On The Job” Is Widespread And Expensive.“. Compliance Solutions Canada December 2, 2009 http://www.compliancesolutionscanada.com/articles/pub_lib45.asp

References• Daniel M Olds, Sean P. Clark & Lawrence s.

Bloomberg. The effects of Work Hours on Adverse Events and Errors in Health Care. National Institute of Health (NIH) Public Access Published as: J safety Res. 2010 April; 41(2): 153-162. dos:10.1016/j.jsr2010.02.002

• Fitzgerald, Beth. Healthcare “Cap on Mandatory Overtime, the Right RX for Nursing Care”. Feb 11, 2012

References

• Frankel Allan, Federico Frank & Leonard Michael; Accountability and the Reality of the human condition. Chapter 3 pg- 24: Joint Commission on Accreditation of Healthcare organizations (Resources) and the Institute for Health care Improvement. Frankel Allan M.D. et al: The Essential Guide for Patient Safety Officers

References

• Rogers Ann E, et al: The working hours of hospital staff nurses and patient safety. Health Affairs, 2004; 23(4):202-212

• Martin Moore-Ede, M.D., Ph.D; Human Fatigue http://www.circadian.com/index.php?option=com_content&view=article&id=162&Itemid=140

Questions ?

• Contact Information • Christine Pontus, MS, RN, COHN-S/CCM• Massachusetts Nurses Association• Associate Director Health & Safety• 340 Turnpike St.• Canton, MA. 02021 • 781-830-5754 (work)• 781-821-4445 (fax