That’s the warning from a recent Joint Commission Sentinel Event Alert (downloadable pdf).

While fatigue certainly is never the only cause of adverse events, it’s a leading factor in many of them, as demonstrated by numerous studies.  Besides increasing the risk to patients, the Alert noted that it puts health care workers’ own safety in jeopardy as well.

In response, the Joint Commission made the following nine recommendations regarding the prevention and management of fatigue as well as creating a safety culture for all health care organizations:

1. Assess your organization for fatigue-related risks. This includes an assessment of off-shift hours and consecutive shift work and a review of staffing and other relevant policies to ensure they address extended work shifts and hours.

2. Since patient hand-offs are a time of high-risk – especially for fatigued staff – assess your organization’s hand-off processes and procedures to ensure that they adequately protect patients.

3. Invite staff input into designing work schedules to minimize the potential for fatigue.

4. Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue. These strategies can include: engaging in conversations with others (not just listening and nodding); doing something that involves physical action (even if it is just stretching); strategic caffeine consumption (don’t use caffeine when you’re already alert and avoid caffeine near bedtime); taking short naps (less than 45 minutes).

5. Educate staff about sleep hygiene and the effects of fatigue on patient safety. Sleep hygiene includes getting enough sleep and taking naps, practicing good sleep habits (for example, engaging in a relaxing pre-sleep routine, such as yoga or reading), and avoiding food, alcohol or stimulants (such as caffeine) that can impact sleep.

6. Provide opportunities for staff to express concerns about fatigue. Support staff when appropriate concerns about fatigue are raised and take action to address those concerns.

7. Encourage teamwork as a strategy to support staff who work extended work shifts or hours and to protect patients from potential harm.20 For example, use a system of independent second checks for critical tasks or complex patients.

8. Consider fatigue as a potentially contributing factor when reviewing all adverse events.

9. If current policy allows for sleep breaks, assess the environment provided for sleep breaks to ensure that it fully protects sleep. Fully protecting sleep requires the provision of basic measures to ensure good quality sleep, including providing uninterrupted coverage of all responsibilities (including carrying pagers and phones, and coverage of both admissions and all continuing care by another provider), and providing a cool, dark, quiet, comfortable room, and, if necessary, use of eye mask and ear plugs.

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The alert points out that 25% of suicides reported took place in non-psychiatric settings. Many of the patients who committed suicide had no history of psychiatric problems or suicidal attempts.

Risk factors for these patients include dementia, traumatic brain injury, chronic pain, intense acute pain, substance abuse, a poor prognosis or terminal diagnosis.

The alert urges health care providers to be more vigilant about the risk of suicide in these patients and to educate caregivers on warning signs of suicidal attempts.

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The most recent Sentinel Event Alert includes a reminder that homicide, rape and assault are routinely among the 10 most common serious events reported to the JC. Worse, it’s believed that those types of attacks are significantly under-reported.

The JC urges health care facilities to take several steps to reduce the risk of violence, including:

• Evaluating the risk of violence by reviewing crime rates and employees’ perception of risk
• Increasing security in the emergency department — especially for facilities in areas with high-crime rates or known gang activity
• Conducting more through background checks on employees, and
• Encouraging staffers to report all incidents, including perceived threats.

Read the full report here.

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Reported events Jan.1 through Sept. 30, 2009:

• Wrong-site surgery — 126
• Unintended retention of foreign body — 97
• Delay in treatment — 94
• Operative/Post-op complications — 79
• Suicide — 72
• Patient fall — 65
• Medication error — 34
• Assault, rape or homicide — 27
• Perinatal death or loss of function — 26
• Patient death or injury in restraints — 9

Since JCAHO started tracking sentinel events in ’95, more than 6,500 patients have been affected, with 68% of the events resulting in death.

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