Fatigue and charting errors: the benefit of reduced call schedule

AORN Journal,  July, 2008  by Anna Warren,  Rebecca Creech Tart

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The OR is a high-pressure, dynamic environment in which a variety of practitioners work together to ensure a successful outcome for every patient. This complex system relies on the competent performance of all surgical team members. Providing care for patients requiring urgent or emergent care after regular hours of operation is an integral part of perioperative nursing. Responsibilities referred to as "call" are assignments that require staff members to be available for unplanned urgent or emergent procedures or to provide care for patients whose procedures do not occur during routine OR hours? Often, nurses who are on call must provide safe patient care while dealing with interrupted sleep or no sleep. Scheduled call rotations and assigned 12-hour work shifts can leave staff members fatigued and prone to making errors, which can negatively affect patient outcomes.

Fatigue is the inability or unwillingness to continue effective performance of a physical or mental task. (2) Fatigue can be caused by time on task, workload, circadian rhythm alterations, sleep debt, shift work, or illness. (3) According to the "AORN guidance statement: Safe on-call practices in perioperative practice settings,"(1) the effects of sleep deprivation as a result of prolonged work hours can mimic alcohol intoxication to the extent that arriving at work fatigued is similar to arriving at work intoxicated. As little as one hour of sleep loss daily can accumulate and result in decreases in attention span, reaction time, and problem-solving ability. (4) As sleep debt mounts, cognitive processes slow, reaction times and concentration begin to diminish, vigilance is lowered, and emotional lability becomes evident. (5)

One study that explored the safety implications of nurses' sleep and work hours indicated that sleep duration was a significant predictor of error occurrences at work. (6) The report also indicated that nurses who had more sleep were more likely to recognize someone else's error, suggesting that rested nurses were more engaged at work.

It has been reported by Helmreich and Davies that training for physicians and airline pilots has tended toward emphasizing personal invulnerability and a resistance to human weaknesses such as fatigue. (5) In fact, their research indicates the converse in that performance deterioration from sleep deprivation is a major contributor to the commission of errors. (5) The transportation and aviation industries have enacted safeguards to curtail the number of hours truck drivers and airline pilots may work, but the health care industry has been slow to follow suit. (7)

Operating rooms, not unlike industrial settings, contain barriers to safety. Inherent in the perioperative environment, however, is the obligation to provide safe 24-hour care while tracking the cost of supplying that care. Hence, most institutions require personnel to be responsible for patient care for periods longer than 12 hours.

Sleep deprivation in nurses has been demonstrated to affect memory, language, and numeric skills; visual attention; and concentration. (8,9) Loss of sleep also has been shown to increase the risk of accidents and errors while affecting the practitioner's ability to solve problems quickly. (10)

Rogers et al conducted a pioneering study reporting the effects of 12-hour shifts and overtime on errors. (8) The study revealed that work duration, overtime, and the number of hours worked per week have a significant effect on errors. In fact, errors occur more often when nurses work 12 hours or more. Moreover, this research supports the supposition that documentation and transcription errors, medication errors, and procedural errors increase as work hours increase. (8)

According to the Institute of Medicine (IOM) report Keeping Patients Safe: Transforming the Work Environment of Nurses, extended work hours and interrupted sleep patterns can result in fatigue, which can affect cognitive and physical ability. (11) This report called for regulatory bodies to prohibit nurses from working more than 12 hours in a 24-hour period or more than 60 hours in a week. AORN has endorsed the IOM report by urging managers to institute safe on-call staffing plans. (1)

Many times, patient care may be required outside routine OR hours. This can result in staff members becoming fatigued as the work day is prolonged. For the purpose of this project, the decision was made to reduce the number of continuous hours staff members worked at a not-for-profit, Magnet community hospital to allow for greater flexibility in staffing, to decrease overtime, and to reduce perioperative errors. Knowing this practice change could potentially be pivotal with regard to chart documentation performance and staffing costs, an evaluation of the effects of the reduced call schedule was undertaken by the OR director and the director for research and evidence-based practice at this community hospital.

This project was designed to determine whether a significant relationship existed between fatigue, as a result of work hours, and surgical charting errors of nurses working eight-hour, 12-hour, and call shifts. Moreover, a cost/benefit analysis was conducted to determine the financial impact associated with implementing a reduced call schedule.