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					       Staff Nurse Fatigue
       and Patient Safety


       Ann E. Rogers PhD, RN, FAAN
             Associate Professor
University of Pennsylvania School of Nursing
Case Study
Case Study 1
On July 4, 2006, a nurse worked a double shift that
ended at midnight. The nurse had volunteered for
the shifts some time prior to coming to work on July
4 and had arranged to sleep at the hospital
following the shifts because she began another
scheduled 8-hour shift on the Birthing Unit, at 7:00
a.m. on July 5th.
Case Study 1 (cont.)
That morning the nurse made a series of errors that
resulted in the death of a patient
  1) she failed to place the armband on the patient’s
    wrist
  2) at 11:30 pm she removed the patient’s medications
    from the pxyis along with the epidural medications (a
    combination of bupivacaine and fentanyl) that she
    thought might be needed later and placed them on a
    counter in the birthing room
  3) after starting an IV on her patient at 12:06, grabbed
    the bag of what she thought was penicillin and added
    it to the IV without checking the bag, scanning the
    patients wristband or using the bar-code
    administration system
Case Study 1(cont.)
The patient had an almost immediate adverse
reaction and the nurse thinking she was reacting to
the Penicillin stopped the drug and called a code.
Case Study 1(cont.)
The patient had an almost immediate adverse
reaction and the nurse thinking she was reacting to
the Penicillin stopped the drug and called a code.

The nurse was initially charged with a felony
(negligent abuse of a patient, causing great bodily
harm), charges reduced to 2 misdemeanors (non-
pharmacist dispensing and possessing/illegally
obtaining a prescription)
Case Study 1(cont.)
The patient had an almost immediate adverse
reaction and the nurse thinking she was reacting to
the Penicillin stopped the drug and called a code.

The nurse was initially charged with a felony
(negligent abuse of a patient, causing great bodily
harm), charges reduced to 2 misdemeanors (non-
pharmacist dispensing and possessing/illegally
obtaining a prescription)

License suspended for 9 months and no longer
allowed to work any OB/birthing area, ICU, or
critical care areas, or any shift >12 hours
Could it Happen Again?
Goal of Study

To determine if the extended shifts and
overtime worked by full-time hospital staff
nurses had an adverse effect on patient safety
           Participants
895 participants were
predominately female
(93%), middle-aged (mean
age 44.5 ± 8.3,range 22-
66), and Caucasian (82%)
Worked at least 36
hours/week
Were unit based and
employed by a hospital
Were members of the
American Association of
Critical Care Nurses or the
American Nurses
Association
Instruments

Demographic Questionnaire
Logbooks (2)
   28-day record of sleep/wake patterns, work
   hours, difficulties remaining alert on duty and
   errors
The majority of                 ANA
                              Sample
                               No. of
                                         AACN
                                        Sample
                                         No. of
                                                   Total
                                                  Sample
                                                   No. of

nurses no longer              Nurses
                                (%)
                                        Nurses
                                          (%)
                                                  Nurses
                                                    (%)


work traditional   8 hours
                                150
                              (38.3%)
                                           60
                                        (11.9%)
                                                    210
                                                  (23.4%)

8 hour day,        12 hours
                                230
                              (58.7%)
                                          436
                                        (86.2%)
                                                    668
                                                  (74.2%)

evening, or                     12        10        22
                   Other

night shifts                  (3.1%)    (1.9%)    (2.4%)
The majority of                   ANA
                                Sample
                                 No. of
                                           AACN
                                          Sample
                                           No. of
                                                     Total
                                                    Sample
                                                     No. of

nurses no longer                Nurses
                                  (%)
                                          Nurses
                                            (%)
                                                    Nurses
                                                      (%)


work traditional 8                150        60       210
                     8 hours

hour day,                       (38.3%)   (11.9%)   (23.4%)




evening, or night    12 hours
                                  230       436       668


shifts
                                (58.7%)   (86.2%)   (74.2%)




                                  12        10        22
                     Other
                                (3.1%)    (1.9%)    (2.4%)
Shift Durations

 Over one third of the shifts were
scheduled for 12.5 hours or longer, and
43% of the shifts exceeded 12.5
consecutive hours.

There were 44 shifts scheduled for
≥ 20 consecutive hours, and 123 shifts
where nurses worked ≥ 20 consecutive
hours.
     Scheduled and Actual Shift
      Durations (ANA Sample)
% of
Shifts




                                  Hours
     Scheduled and Actual Shift
      Durations (ANA Sample)
% of
Shifts




                                  Hours
     Scheduled and Actual Shift
      Durations (ANA Sample)
% of
Shifts




                                  Longest shift
                                  was 23 hrs,
                                  50 minutes




                                  Hours
     Scheduled and Actual Shift
      Durations (AACN Sample)
% of
Shifts




                                  Hours
     Scheduled and Actual Shift
      Durations (AACN Sample)
% of
Shifts




                                  Longest shift
                                  was 23 hrs,
                                  40 minutes




                                  Hours
Overtime

 Working longer than scheduled was normal
  Nurses rarely left work at the end of their scheduled shift (19%, 13%)
  They averaged almost an hour (55 minutes, 49 minutes)
  extra work/day
  Overtime was less frequent when nurses worked 12-hour shifts (79%
  versus 85%). ANA Sample
Overtime

 Working longer than scheduled was normal
  Nurses rarely left work at the end of their scheduled shift (19%, 13%)
  They averaged almost an hour (55 minutes, 49 minutes)
  extra work/day
  Overtime was less frequent when nurses worked 12-hour shifts
  (79% versus 85%). ANA Sample


 The frequency of mandatory overtime varied
  ANA Sample 360 shifts (7%) were mandated and
   143 voluntary overtime shifts (3%) were coerced
  AACN Sample 263 shifts (16.5%) were mandated and
   152 voluntary overtime shifts (12.3%) were coerced
Errors
Errors

 Just under one-third of the participants
 reported making an error during the data-
 gathering period.



 Near errors were reported by one third of
 the participants.
            Association of Work
            Duration and Errors

                          ANA Sample*                         AACN Sample
Work Duration      No. Shifts   No. shifts   OR (p=     No. Shifts No. shifts   OR (p=
(hours)              (%)         with at      value)      (%)       with at      value)
                                least one                          least one
                                error (%)                          error (%)

                     771           12                     543          11
≤ 8.5                                          1.0                                 1.0
                   (14.4%)       (1.6%)                   (9%)        (2%)

                     2484          77          1.85       1720         46         1.42
> 8.5, < 12.5
                   (46.8%)       (3.1%)       (0.06)     (29%)        (3%)       (0.304)

                     2057          103         3.29       3748         146        1.94
≥ 12.5
                   (38.9%)        (5%)       (0.0001)    (62%)        (4%)       (0.028)

Total                5312          192                    6011        203




 * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs
            Association of Work
            Duration and Errors

                          ANA Sample*                         AACN Sample
Work Duration      No. Shifts   No. shifts   OR (p=     No. Shifts No. shifts    OR (p=
(hours)              (%)         with at      value)      (%)       with at       value)
                                least one                          least one
                                error (%)                          error (%)

                     771           12                     543          11
≤ 8.5                                          1.0                                 1.0
                   (14.4%)       (1.6%)                   (9%)        (2%)

                     2484          77          1.85       1720         46         1.42
> 8.5, < 12.5
                   (46.8%)       (3.1%)       (0.06)     (29%)        (3%)       (0.304)

                     2057          103         3.29       3748         146       1.94
≥ 12.5
                   (38.9%)        (5%)       (0.0001)    (62%)        (4%)      (0.028)

Total                5312          192                    6011         203




 * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs
 Association of Errors with
  Overtime (ANA sample)

      Work Duration                           No. of Shits ≥ 1
                             Overtime                               OR (p-value)
          (hr)                                  error (%)

   ≤ 8.5
                                No             8/377 (2.1%)             1.00

                                Yes           64/2075 (3.1%)         1.34 (0.42)

   > 8.5, <12.5
                                No             6/246 (2.4%)             1.00

                                Yes           36/937 (3.8%)          1.53 (0.36)

   ≥ 12.5
                                No             6/360 (1.7%)              1.0

                                Yes           70/1263 (5.5%)        3.26 (0.005)

   Total                                         191/5258



* Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs
 Association of Errors with
  Overtime (ANA sample)

      Work Duration                           No. of Shits ≥ 1
                             Overtime                               OR (p-value)
          (hr)                                  error (%)

   ≤ 8.5
                                No             8/377 (2.1%)             1.00

                                Yes           64/2075 (3.1%)         1.34 (0.42)

   > 8.5, <12.5
                                No             6/246 (2.4%)             1.00

                                Yes           36/937 (3.8%)          1.53 (0.36)

   ≥ 12.5
                                No             6/360 (1.7%)              1.0

                                Yes           70/1263 (5.5%)       3.26 (0.005)

   Total                                         191/5258



* Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs
Sleepy Nurses
Difficulties Remaining Alert
   on Duty Were Common


                        ANA Sample       AACN Sample
                       No. Nurses (%)   No. Nurses (%)

Reported at least on
episode of
struggling to stay      196 (60.8%)      324 (64.4%)
awake during the
shift
Reported at least
one episode of
                        86 (21.9%)       66 (13.0%)
falling asleep on
duty
 Difficulties Remaining Alert
on Duty Were Common (cont.)


                       No. Shifts (%)   No. Shifts (%)
                        ANA Sample      AACN Sample


 Reported struggling
 to stay awake         1068 (20.3%)     1217 (20.1%)
 during shift


 Reported falling
                        269 (5.1%)       180 (3.0%)
 asleep on duty
    Time of Day When Nurses Reported
Difficulties Remaining Alert (Both Samples)
     No. of
     Shifts




                               Time of Day
    Time of Day When Nurses Reported
Difficulties Remaining Alert (Both Samples)
     No. of
     Shifts




                               Time of Day
Long Work Hours Adversely Affect
    Vigilance (AACN Sample)

                         Struggling to Stay
                                                        Fell Asleep on Duty
   Work Duration          Awake on Duty
     (hours)
                   No. shifts (%)   OR (p-value)   No. Shifts (%)   OR ( p-value)


       ≤ 8.5         77 (14%)           1.0          4 (0.7%)           1.0




    > 8.5, <12.5    279 (16%)       1.1 ( 0.695)    30 (1.8%)        1.9 (0.043)




      ≥ 12.5        847 (23%)       1.15 (0.007)    44 (3.9%)       2.40 (0.014)




       Total           1203                             178
Long Work Hours Adversely Affect
    Vigilance (AACN Sample)

                         Struggling to Stay
                                                        Fell Asleep on Duty
   Work Duration          Awake on Duty
     (hours)
                   No. shifts (%)   OR (p-value)   No. Shifts (%)   OR ( p-value)


       ≤ 8.5         77 (14%)           1.0          4 (0.7%)           1.0




    > 8.5, <12.5    279 (16%)       1.1 ( 0.695)    30 (1.8%)        1.9 (0.043)




      ≥ 12.5        847 (23%)       1.15 (0.007)    44 (3.9%)       2.40 (0.014)




       Total           1203                             178
Long Work Hours Adversely Affect
    Vigilance (AACN Sample)

                         Struggling to Stay
                                                        Fell Asleep on Duty
   Work Duration          Awake on Duty
     (hours)
                   No. shifts (%)   OR (p-value)   No. Shifts (%)   OR ( p-value)


       ≤ 8.5         77 (14%)           1.0          4 (0.7%)           1.0




    > 8.5, <12.5    279 (16%)       1.1 ( 0.695)    30 (1.8%)       1.9 (0.043)




      ≥ 12.5        847 (23%)       1.15 (0.007)    44 (3.9%)       2.40 (0.014)




       Total           1203                             178
Sleepy nurses
can endanger
the general
public
Drowsy Driving Was Common


                       ANA Sample     AACN Sample

No. nurses reporting   263 (66.9%)      331 (65.9%)
≥ 1 episode of
drowsy driving


No. of shifts with     1281 (24.6%)     1639 (27.5%)
drowsy driving
Drowsy Driving Wasn’t Just a
One Time Occurrence
  number of times that drowsy driving was
reported ranged from 1-20 times
  only 21% of those who reported struggling to
stay awake driving home, reported it only once
  just under 1/4 of participants reported struggling
to stay awake driving home from work at least
75% of the time
 30 nurses (5%) reported difficulties staying
awake driving home after every shift they worked
Factors Associated with Drowsy
Driving
  Working 12-hour shifts doubled the risk of drowsy
driving
 Longer commutes
  Working at night (at least 6 hours between 2200
and 0600) nearly quadrupled the risk of struggling
to stay awake driving home
Nurses Who Struggled To Stay Awake
 Driving Home Obtained Less Sleep

                                ANA Sample     AACN Sample
Drowsy Drivers
  Mean sleep duration (hrs)      6.37 ± 2.01     6.3 ± 2.10
  Median sleep duration (hrs)        6.5             6.2

Alert Drivers
  Mean sleep duration (hrs)      6.89 ± 1.63    6.77 ± 1.65
  Median sleep duration (hrs)       6.98           6.75
Acknowledgements

 David Dinges PhD      American Association
                       of Critical Care Nurses
 Wei-Ting Hwang
                       American Nurses
 PhD
                       Association
 Linda Scott PhD, RN   Agency for Healthcare
                       Research and Quality
                       (R01 HS11963)
                       American Nurses
                       Foundation Grant
                       (Scott)

				
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posted:8/14/2012
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