Transcript References Barger LK, et al

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
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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
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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 nonmedical 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 FATIGUE
Martin 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_c
ontent&view=article&id=162&Itemid=140
Causes of Fatigue
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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 injury
to 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 skills
Productivity & performance
Attention & vigilance
Ability to handle stress on the job
Reaction 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 19962006.
• 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
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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
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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 extendedduration 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_lib
45.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=1
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Questions ?
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• 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