Wake up your zombie workforce to patient safety risks

Karen Cheung

 Karen M. Cheung

Is your hospital a hotspot for the walking dead?

A study in published in the Archives of Surgery uncovered more evidence that sleepy surgeons are a threat to patient safety--and the news is making its way through the mainstream media (and reaching your patients).

On average, a surgical resident gets 5.3 hours of sleep a day, according to a study of orthopedic surgical residents at Boston's Massachusetts General Hospital and Brigham and Women's Hospital, with some residents only getting 2.8 hours a night.

What's even more alarming is that during a quarter of their waking hours, surgical residents' fatigue is akin to being legally drunk, meaning that they are functioning at 70% mental effectiveness (correlating with a blood alcohol level of 0.08%).

Although we've heard sobering statistics such as these before, the study did call out the pervasiveness of fatigue and how it affects patient care. Fatigued residents have a 22 percent greater risk of causing a medical error than alert, well-rested doctors, according to the study.

The Accreditation Council for Graduate Medical Education (ACGME) took great steps to limit resident work hours when it finalized duty hour rules in 2011, years after the ACGME adopted the groundbreaking 80-hour limit in 2003 and the landmark Institute of Medicine report in 2008.

The problem is so significant that that the largest accrediting body declared it a sentinel event in December 2011, when The Joint Commission warned hospitals about the potential dangers of extended hours and excessive workloads, not just for residents but for all healthcare workers.

"Imagine an intoxicated person working in a hospital setting, and you'll have a better understanding of the dangers of being fatigued,"  Frederick Southwick, professor at the University of Florida and manager of New Quality and Safety Initiatives for the University of Florida and Shands Health Care System, wrote in yesterday's Hospital Impact blog post.

We wouldn't let a drunk physician into the operating room. Why would we tolerate a sleepy surgeon?

Part of the sleep problem stems from the glutton-for-punishment mentality so persuasive in medical and nursing school for years. But the call to patient safety requires a severe change in culture.

"In this era of ever-increasing medical complexity, the most important realization is that no one can do it all," Southwick said. "Teamwork is vital for efficient care; each professional caregiver possesses unique and equally important expertise that should be shared."

Southwick noted it's not just individual variables such as fatigue that factor into the problem of adverse events. There's emotional stress on providers, as well as the pressure to multitask. Southwick pointed out there also are systemwide problems, such as nursing ratios (or what Southwick referred to as "skeleton crews" at night and on weekends).

The fatigue factor, however, is one area in which the healthcare industry can start to take control.  
The Joint Commission in its Sentinel Event Alert suggested organizations assess their fatigue-related risks, including limiting off-shift hours and consecutive shift work; examining the hand-off process; inviting staff to offer input in their own work schedules; implementing a fatigue management plan; and educating staff about the effects of fatigue on patient safety.

It's unlikely that the problem of resident fatigue is going to go away altogether, but the immediate threat that fatigue poses on patient safety requires immediate action--hospitals must consider their staffing rations and redesigning shifts now.  - Karen (@FierceHealth)