Ann E. Rogers PhD, RN, FAANAssociate Professor

University of Pennsylvania School of Nursing

Ann E. Rogers PhD, RN, FAANAssociate Professor

University of Pennsylvania School of Nursing

Staff Nurse Fatigue and Patient Safety

Staff Nurse Fatigue and Patient Safety

Case StudyCase Study

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.

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 1Case Study 1

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

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.)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 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.)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)

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.)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

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

Case Study 1(cont.)Case Study 1(cont.)

Could it Happen Again?Could it Happen Again?

To determine if the extended shifts and overtime worked by full-time hospital staff nurses had an adverse effect on patient safety

To determine if the extended shifts and overtime worked by full-time hospital staff nurses had an adverse effect on patient safety

Goal of StudyGoal of Study

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

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

ParticipantsParticipants

Demographic Questionnaire

Logbooks (2) 28-day record of sleep/wake patterns, work hours, difficulties remaining alert on duty and errors

Demographic Questionnaire

Logbooks (2) 28-day record of sleep/wake patterns, work hours, difficulties remaining alert on duty and errors

InstrumentsInstruments

The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

ANA Sample No. of Nurses

(%)

AACN Sample No. of Nurses

(%)

Total Sample No. of Nurses

(%)

8 hours150

(38.3%)60

(11.9%)210

(23.4%)

12 hours

230 (58.7%)

436 (86.2%)

668 (74.2%)

Other12

(3.1%)10

(1.9%)22

(2.4%)

The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

ANA Sample No. of Nurses

(%)

AACN Sample No. of Nurses

(%)

Total Sample No. of Nurses

(%)

8 hours150

(38.3%)60

(11.9%)210

(23.4%)

12 hours

230 (58.7%)

436 (86.2%)

668 (74.2%)

Other12

(3.1%)10

(1.9%)22

(2.4%)

Shift DurationsShift 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.

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)

Scheduled and Actual Shift Durations (ANA Sample)

HoursHours

% ofShifts% ofShifts

% ofShifts% ofShifts

Scheduled and Actual Shift Durations (ANA Sample)

Scheduled and Actual Shift Durations (ANA Sample)

HoursHours

% ofShifts% ofShifts

Scheduled and Actual Shift Durations (ANA Sample)

Scheduled and Actual Shift Durations (ANA Sample)

HoursHours

Longest shiftwas 23 hrs, 50 minutes

HoursHours

% ofShifts% ofShifts

Scheduled and Actual Shift Durations (AACN Sample)

Scheduled and Actual Shift Durations (AACN Sample)

HoursHours

% ofShifts% ofShifts

Scheduled and Actual Shift Durations (AACN Sample)

Scheduled and Actual Shift Durations (AACN Sample)

Longest shiftwas 23 hrs, 40 minutes

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

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

OvertimeOvertime

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

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

OvertimeOvertime

ErrorsErrors

ErrorsErrors

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.

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 ErrorsAssociation of Work Duration and Errors

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

Work Duration (hours)

ANA Sample* AACN Sample

No. Shifts (%)

No. shifts with at

least one error (%)

OR (p= value)

No. Shifts (%)

No. shifts

with at least one error (%)

OR (p= value)

≤ 8.5771

(14.4%)12

(1.6%)1.0

543 (9%)

11 (2%)

1.0

> 8.5, < 12.52484

(46.8%)77

(3.1%)1.85

(0.06)1720 (29%)

46 (3%)

1.42 (0.304)

≥ 12.52057

(38.9%)103 (5%)

3.29 (0.0001)

3748 (62%)

146 (4%)

1.94 (0.028)

Total 5312 192 6011 203

Association of Work Duration and ErrorsAssociation of Work Duration and Errors

Work Duration (hours)

ANA Sample* AACN Sample

No. Shifts (%)

No. shifts with at

least one error (%)

OR (p= value)

No. Shifts (%)

No. shifts with at

least one error (%)

OR (p= value)

≤ 8.5771

(14.4%)12

(1.6%)1.0

543 (9%)

11 (2%)

1.0

> 8.5, < 12.52484

(46.8%)77

(3.1%)1.85

(0.06)1720 (29%)

46 (3%)

1.42 (0.304)

≥ 12.52057

(38.9%)103 (5%)

3.29 (0.0001)

3748 (62%)

146 (4%)

1.94 (0.028)

Total 5312 192 6011 203

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

Work Duration (hr)

OvertimeNo. of Shits ≥ 1

error (%)OR (p-value)

≤ 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* Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

Association of Errors withOvertime (ANA sample)

Association of Errors withOvertime (ANA sample)

Work Duration (hr)

OvertimeNo. of Shits ≥ 1

error (%)OR (p-value)

≤ 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* Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

Association of Errors withOvertime (ANA sample)

Association of Errors withOvertime (ANA sample)

Sleepy NursesSleepy Nurses

Difficulties Remaining Alert on Duty Were Common

Difficulties Remaining Alert on Duty Were Common

ANA SampleNo. Nurses (%)

AACN Sample No. Nurses (%)

Reported at least on episode of struggling to stay awake during the shift

196 (60.8%) 324 (64.4%)

Reported at least one episode of falling asleep on duty

86 (21.9%) 66 (13.0%)

Difficulties Remaining Alert on Duty Were Common (cont.)Difficulties Remaining Alert

on Duty Were Common (cont.)

No. Shifts (%)ANA Sample

No. Shifts (%)AACN Sample

Reported struggling to stay awake during shift

1068 (20.3%) 1217 (20.1%)

Reported falling asleep on duty

269 (5.1%) 180 (3.0%)

Time of DayTime of Day

No. of Shifts

No. of Shifts

Time of Day When Nurses Reported Difficulties Remaining Alert (Both

Samples)

Time of Day When Nurses Reported Difficulties Remaining Alert (Both

Samples)

Time of DayTime of Day

No. of Shifts

No. of Shifts

Time of Day When Nurses Reported Difficulties Remaining Alert (Both

Samples)

Time of Day When Nurses Reported Difficulties Remaining Alert (Both

Samples)

Work Duration (hours)

Struggling to Stay Awake on Duty

Fell Asleep on Duty

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)

Long Work Hours Adversely Affect Vigilance (AACN Sample)

Scott et al (under review) The effects of critical care nurse work hours on vigilance and patient safety

Work Duration (hours)

Struggling to Stay Awake on Duty

Fell Asleep on Duty

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)

Long Work Hours Adversely Affect Vigilance (AACN Sample)

Scott et al (under review) The effects of critical care nurse work hours on vigilance and patient safety

Work Duration (hours)

Struggling to Stay Awake on Duty

Fell Asleep on Duty

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)

Long Work Hours Adversely Affect Vigilance (AACN Sample)

Scott et al (under review) The effects of critical care nurse work hours on vigilance and patient safety

Sleepy nursescan endangerthe general public

Sleepy nursescan endangerthe general public

ANA SampleAACN Sample

No. nurses reporting ≥ 1 episode of drowsy driving

263 (66.9%) 331 (65.9%)

No. of shifts with drowsy driving

1281 (24.6%) 1639 (27.5%)

Drowsy Driving Was Common

Drowsy Driving Was Common

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

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

Drowsy Driving Wasn’t Just a One Time Occurrence

Drowsy Driving Wasn’t Just a One Time Occurrence

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

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

Factors Associated with Drowsy DrivingFactors Associated with Drowsy Driving

Nurses Who Struggled To Stay Awake Driving Home Obtained

Less Sleep

Nurses Who Struggled To Stay Awake Driving Home Obtained

Less Sleep

ANA Sample

AACN Sample

Drowsy Drivers Mean sleep duration (hrs) Median sleep duration (hrs)

6.37 ± 2.016.5

6.3 ± 2.106.2

Alert Drivers Mean sleep duration (hrs) Median sleep duration (hrs)

6.89 ± 1.636.98

6.77 ± 1.656.75

David Dinges PhD

Wei-Ting Hwang PhD

Linda Scott PhD, RN

David Dinges PhD

Wei-Ting Hwang PhD

Linda Scott PhD, RN

AcknowledgementsAcknowledgements

American Association of Critical Care Nurses

American Nurses Association

Agency for Healthcare Research and Quality (R01 HS11963)

American Nurses Foundation Grant (Scott)

American Association of Critical Care Nurses

American Nurses Association

Agency for Healthcare Research and Quality (R01 HS11963)

American Nurses Foundation Grant (Scott)