"We understand that fatigue has been a contributing factor in many adverse events that we analyze – the Joint Commission reviews some 900 sentinel events every year; fatigue has played a role in many of these," says Ana McKee, the commission's executive vice president and chief medical officer who helped prepare the alert.
According to the alert, "the healthcare industry has been slow to adopt changes, particularly with regard to nursing" to prevent fatigue-related preventable healthcare-associated mishaps.
The alert quotes Ann Rogers, a sleep medicine expert with Emory University in Atlanta, as saying, "We have been slow to accept that we have physical limits and biologically, we are not built to do the things we are trying to do."
McKee says that routine root cause analyses performed after adverse events usually take into consideration worker alertness. For example, investigators try to assess "what was the capacity of the individuals involved? Had they worked extra shifts, were they short on staff so people extended their time?