Joint Commission gives hospitals a wake-up call on fatigue risks
Joint Commission gives hospitals a wake-up call on fatigue risks
But OSHA balks at adding more enforcement
Hospitals have been put on alert to recognize fatigue among health care workers as a risk to patient safety. But for now, hospitals won't face any regulatory consequences for failing to address it.
The U.S. Occupational Safety and Health Administration 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 health care 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, which is based in Oakbrook Terrace, IL, noting that fatigue has not been widely addressed in hospitals.
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 findings that are creating pressure for health care employers to limit shift length and overtime.
In 2004, an Institute of Medicine panel recommended state rules to restrict nurses to shifts of no more than 12 hours in a 24-hour period and a work week of no more than 60 hours in seven days.1 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 a four-week period. All of them worked at least one day of overtime, and about a third worked overtime every day they worked. More than a quarter (28.7%) reported working mandatory overtime at least once during that timeframe.2
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.
"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," says 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. "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 hospitals to involve employees in designing work schedules that minimize fatigue. But many nurses actually prefer the 12-hour shifts, notes Rogers.
"Everybody likes 12-hours shifts because you have more days off, but what people don't realize is that they're fatigued the next day," she says. "People are very poor judges of their own alertness and fatigue. While others may recognize that they're tired, they may not."
While 12-hour shifts may be here to stay, at least for the foreseeable future, hospitals should create strict limits on overtime and overall work hours, Rogers advises. "Make sure the workload is such that [nurses] can leave at the end of the 12 hours. They should have no more than three consecutive 12-hour shifts," she says. "You're going to be so short on sleep that you're profoundly fatigued. This is even more critical for the night shift worker."
Can OSHA enforce ACGME rules?
Public Citizen, a consumer and health advocacy organization based in Washington, DC, is still hoping to influence OSHA to address fatigue in health care.
OSHA should use its existing authority to enforce the ACGME limits on medical resident duty hours and to address fatigue in health care, Public Citizen said in a letter to Michaels. OSHA could issue financial penalties under the general duty clause and provide medical residents with whistleblower protection, says Sammy Almashat, MD, MPH, staff researcher with Public Citizen's Health Research Group.
"If OSHA went in to hospitals [on an inspection], they could enforce violations of the ACGME rules that already exist," he says.
Public Citizen had asked for rulemaking on work hours, but the rulemaking process has been notoriously slow and politically delicate for OSHA. In his response, Michaels noted, "OSHA's decision comes at a time when the agency faces significant challenges. Unfortunately, OSHA must prioritize limited resources and cannot move forward on every rulemaking request."
Federal rules currently set work limits for some other safety sensitive industries, such as trucking, nuclear power and airlines. But for now, health care 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 time cards to make sure nurses aren't working excessive amounts of overtime, she says.
Employees also need to understand the safety risks and make sure that they get enough sleep, says McKee. After all, work isn't the only reason that health care workers may fail to get adequate sleep.
"There is some responsibility and accountability on the part of the health care worker to come to work rested. That can't be regulated or mandated," she says. "It's something each individual has to be accountable for [as part of] the professionalism that we all have."
References
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.
Hospitals have been put on alert to recognize fatigue among health care workers as a risk to patient safety. But for now, hospitals won't face any regulatory consequences for failing to address it.Subscribe Now for Access
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