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)