"You might hear that there was a staffing shortage, or someone called in sick and was unable to be relieved so someone else did a double shift. It's not uncommon to hear that these are contributors when an adverse event happens," McKee says.
As healthcare executives look to the labor force to impose cuts, healthcare worker fatigue is something that can become an even bigger problem, potentially being a factor in more errors in patient care, she says. "Whenever an organization is restrained financially, staffing is always affected, and [increased numbers of adverse events are] a potential consequence."
McKee emphasizes that the sentinel alert notice was not provoked by any one incident, but by a number of studies linking adverse events to worker fatigue.
"We just felt it's time," McKee says. "The Accreditation Council for Graduate Medical Education (ACGME) has addressed this by reducing residents' hours" to a maximum of 30 hours per work shift and a maximum of 80 hours per week. "And we wanted to recognize that this is not a risk just to residents, but to all healthcare workers."
10 signs and symptoms of fatigue
Among the studies listed to underscore the need to prevent fatigue, the commission's alert noted one in 2004 which revealed that nurses who work shifts of 12.5 hours or longer "are three times more likely to make an error in patient care," and that workers in shifts in excess of 12 hours suffer higher rates of occupational injury.