Anesthesia Management: Worker fatigue cause of health care mistakes, study finds

This is important no matter what department you practice in.

Health care worker fatigue contributed to more than 1,600 incidents reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS), with 37 considered harmful and four resulting in patient deaths, according the Pennsylvania Patient Safety Authority.

An article released from the PPSA’s June advisory examined data from June 2004 to August 2013, and found there were 1,601 events reported in which health care worker fatigue was cited as a factor. Medication errors were most common, making up 62.1 percent of the errors, the article said. Errors related to a procedure, treatment or test was the next most common, at 26 percent.

Though the overwhelming majority of the errors did not result in harm to the patient, there were four deaths among the 37 incidents classified as harmful.

“Recent literature shows that one of the first efforts made to reduce events related to fatigue was target limiting the hours worked,” said Dr. Theresa Arnold, manager of clinical analysis for the Pennsylvania Patient Safety Authority. “However, further study suggests a more comprehensive approach is needed, as simply reducing hours does not address fatigue that is caused by disruption in sleep and extended work hours.”

Arnold said fatigue is defined “as an overwhelming sense of tiredness, lack of energy and feeling of exhaustion associated with impaired physical and/or cognitive functioning.”

“In studies conducted with nurses, it was shown that working a 12-hour work shift or working overtime is associated with difficulties staying awake while on duty, reduced sleep times, and nearly triple the risk of making an error,” Arnold said. “The most significant error risk observed was when nurses worked 12.5 hours or longer. Many hospitals have adopted 12-hour shifts as the norm and it is a similar choice among nurses who want to limit the number of days they work in a week, but research on the 12-hour shift and patient safety needs further review.”

Worker fatigue is one of the contributing factors that may be selected when a facility files an event report with the PA-PSRS.

The five locations in which events occurred were medical-surgical, emergency, pharmacy, general medical ward and the laboratory. Incorrect medication dosage, dose admission and extra medication doses were the most common medication errors.