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Linking Medical Errors, Nurses' 12-Hour Shifts

Rebecca Hendren, for HealthLeaders Media, October 5, 2010

It's well known that caregiver fatigue is a huge cause of medical errors, whether the caregiver involved is a new resident coming off a marathon week or an overworked nurse pulling back-to-back shifts.

A few months ago, the Accreditation Council for Graduate Medical Education placed new restrictions on the hours residents can work and the supervision they receive. This follows years of research into new physicians' training and the effect long hours and tiredness play in performance and contribute to poor quality care. A 2004 study found that first-year residents working all night were responsible for more than half of preventable adverse events.

Nurses don't have the same extraordinarily-long work requirements as residents—and they clearly perform very different tasks—but like residents, they work long shifts and suffer from fatigue. Studies have linked nurse fatigue with medical errors, poor quality care, stress, and burnout.

There are many reasons for nurse fatigue, but one stands out as pretty easy to fix: shift length. It's no wonder that nurses are fatigued when 12-hour shifts are the norm. Despite the fact the Institute of Medicine has recommended limiting use of 12-hour shifts, it's standard practice throughout the profession. Nurses routinely work back-to-back-to-back 12-hour shifts.

At the recent Nursing Management Congress in Grapevine, TX, held September 23-25, I attended a presentation by Cole Edmonson, CNO/vice president of patient care services at Texas Health Presbyterian Hospital in Dallas. Edmonson noted that research is helping us understand the dangers nurse fatigue presents to patients and to nurses themselves. He called 12-hours shifts a dead idea whose time has passed and suggested they may cause more problems than they solve. He asked attendees whether it is time to declare the end of 12-hour shifts.

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38 comments on "Linking Medical Errors, Nurses' 12-Hour Shifts"


John Smith (4/15/2013 at 10:25 AM)
My daughter like the 12 hrs. shift but I'm concern about the number of nurses accidents driving back home after the third 12 hrs. shift on top of the possible medical errors.

EMR Saves Lives (10/23/2010 at 9:34 AM)
This is common sense. Scheduling problems are notorious in hospitals and nursing homes. I feel bad for the patients and the nurses.

Kit (10/20/2010 at 2:42 PM)
The comments I have read are very interesting. Let's consider some of the science behind safety . 1-Cognitive load (CL) counts ( When RN's note: There is " too much input to cope with") This load is defined by the total patient numbers/acuity. Regular measurement of this load is recommended by laudable nursing researchers like Dr. Aiken. This load is further defined by the National Nurses United (NNU). Their nurse attorneys, scientists & 150,000 members recognize the CL challenge. The NNU also recommends system based solutions like those used in the airline industry. Moreover the NNU mandates consistent external reporting to reduce CL. <*Documenting assignment that are at risk for high CL> 2- Compassion fatigue counts ( When RN's note: There is " too much sadness to cope with") Recent data finds many fatigued staff work with patients demonstrating low Years of Productive Life Left <YPLL> . Examples of high risk units with low YPLL include ICU, palliative care, heme-onc , gero-psych & emergency departments. Staff fatigue that occurs after coping with low YPLL patients, eventually results in compassion challenges. Those challenges may be most evident towards the patients who frequently don't show medical improvement. This can compound errors in a high risk cohort. This concern for compassion fatigue extends into refugee care as well. That is, some care is too "hot" to do over an extended period. Compassion fatigue can occur readily in nursing/refugee partnerships unless there are system based approaches to reduce it. As a result, fatigue researchers would concur with previous postings. That is, they may question whether RNs can manage a high care burden five out of seven days per week. They would likely counter that the care demand in five days straight is too excessive. That would seem logical since many hospitalized populations are simply very vulnerable and needy. The likely result is that the patients and their caregivers become dysphoric regularly. In addition, this inherent compassion fatigue risk is already managed with spacing interventions within the respite care movement. The NHPCO, or the lead hospice oversight group, has noted the challenge there as well. For instance, the prevalence of major depressive disorder in hospice caregivers approaches 40%. Hospital nurses are impacted; therefore, by both the dysphoria of the patient & their caregivers. As a consequence, finding optimal hours to have good nurses care for this population is important. It is equally important to schedule respite into any safe system that patients and RNs interface with. 3- Social velocity counts ( When RN's note : There are "too many voices to hear") If you regularly add overtime, have a heavy unit or many anxious families, your RNs are likely to be fatigued. The total number of calls & 24/7 open visitation also adds to this fatigue. If the RN must manage a unit or pick up for a late desk clerk, the risks go up for the patients again. This cumulative social velocity adds to the potential for judgment errors. It is also one of the reasons that quiet rooms are being considered again for medicine distribution. Nurses need to think and they need quiet at some part of the day to do that or systemic errors will occur. 4- Environmental challenges count (When RN's note: There is "too much background distraction to focus") Recent med-surg data shows these units are above OSHA recommendations for noise. This may be exacerbated as the elders require greater numbers of telemetry, C-PAP and fall monitors. In addition, a recent Institute for Safe Med Practices (ISMP) report noted that 17,000 RNs refuted the practical nature of the CMS med administration guidelines. While the CMS guidelines were initiated with the best intentions , they added to the stress for the RN team. Human factors, like the practicality for an RN team, must always be calculated into health care standards. My summation from this research is that an RN can't provide safe direct care five days a week. It would be possible; however, to have an RN work 36 hours week one + 32 hours week two or 68 hours per pay period. That direct care aggregate should be an FTE. (Benefits eligible). In addition, this schedule would allow for some 8 & 12 hour options. Unlike employees who deal with retrospective data, the RN must use iterative judgment and act expeditiously under stress. As a consequence, I argue that additional time beyond 68 hours should be used towards passive duties. These RN projects could still benefit the patient if they included meetings, precept development & oversight for novice MDs. ============================== The central challenge is we need to keep a nursing body. An additional challenge is that nurses & American patients in aggregate are aging. As a result, we need to keep pace with new safety data. I ask my colleagues to offer other suggestions for improving the total nursing representation in that care number. From my perspective, a few cost sensitive safety strategies could be considered to help the already burdened teams: a- The hospitals should consider LPN training to improve chronic care. b- EMTs should be allowed to help RNs on acute units. c- RRTs should be mandated to assist with challenging interventions d- Nursing ratios be mandated with outlier hospitals surveyed more frequently. Thanks in advance for reading & wishing you all the best, kit, FNP-c MPH