Lack of sleep another safety risk factor - Editorial - medical errors

Nancy J. Girard

A terrible accident occurred recently when a car driving on an interstate highway suddenly veered across the median and smacked head-on into an 18-wheel truck. The entire family in the car was killed instantly. An investigation determined that the car's driver had fallen asleep at the wheel. Family members later said the car's occupants were on their way home from a vacation and had decided to drive all night to avoid paying for a motel room. This tragedy occurred because of sleep deprivation, and it should not have happened.

Although this is an example of an extreme consequence of sleep deprivation that luckily does not happen often, lack of sleep has been identified as a major contributing factor to accidents. Indeed, people with sleep apnea leading to loss of sleep have been found to have as high an incidence of traffic accidents as people who are under the influence of alcohol. (1) Drivers who have not had enough sleep can have driving problems that are comparable to those experienced by people with modest blood alcohol levels. The loss of as little as three hours of usual sleep affects an individual's ability to maintain a consistent speed and a stable road position. (2)

Safety is a factor wherever loss of sleep exists. Sleep deprivation has been related to an increase in industrial accidents, poor academic performance, delays in recovery from hospitalization, and misdiagnoses mad errors in health care settings. For example, one study found that attending physicians were slower in performing intubations and had slower general reaction times when they were sleep deprived. This was especially evident as the physicians rotated through the night shift. (3)

SLEEP DEPRIVATION

Sleep deprivation is the absence of sleep during a period of time that is determined by an individual's need. The Cochrane Database of Systematic Reviews lists many studies about sleep deprivation that have been conducted across a wide variety of situations. Participations include students, health care professionals, patients, pilots, astronauts, and others. Sleep deprivation's effects can be mild to severe, depending on the length of time a person goes without sleep and the recuperative abilities of the individual. Everyone who has ever been a student (and that includes every nurse) remembers pulling at least one "all-nighter" when studying for exams or finals. Unfortunately, as it turns out, that was exactly the wrong time to be sleep deprived. (4)

After graduation, nurses have jobs and schedules that lead to sleep deprivation. This includes rotating shifts, being on call all night and then working regularly assigned shifts the next day, or working double shifts and having home responsibilities that prevent them from sleeping during precious free hours. (5)

EFFECTS OF SLEEP DEPRIVATION

Effects of sleep loss are fairly well recognized and include slower reaction times, decreased ability to perform fine psychomotor skills, mood changes, cognitive changes, and memory problems. (6) Physiological changes also can result if loss of sleep continues for an extended period of time. Although short-term sleep deprivation does not affect the immune system, some studies have shown that prolonged lack of sleep produces changes in cortisol levels and the immune system, as well as decreases in insulin sensitivity. (7)

Loss of sleep adversely affects the ability to perform tasks that require sustained and continuous attention. (8) It also appears to affect the neural auditory system by slowing the response time between hearing something and reacting to it. Even vocal intonations are affected by sleep deprivation, with tones becoming slower and flatter. (9)

IMPLICATIONS FOR PERIOPERATIVE NURSES

For a surgical team, loss of sleep potentially can create many safety and work problems, including

* risk of increased accidents,

* risk of increased errors,

* decreased ability to quickly solve problems,

* slower reaction and performance time in psychomotor skills, (10) and

* negative impact on the work environment because of mood swings and the decreased ability of sleep-deprived personnel to cope with workplace stress. (11)

The treatment for sleep deprivation is simple--get some sleep. Like most things, however, this is easier said than done. Physicians often have a room in the hospital where they can catch a short nap, but there is no place or time for others on the surgical team to do likewise.

Effects of sleep loss also can be counteracted the old fashioned way; that is, by drinking a couple of cups of strong coffee. (12) Unfortunately, other pharmacological agents also have been used to counteract the effects of sleepiness, which may contribute to safety problems in the OR.

CONCLUSION

Sleep deprivation is an old problem that has resurfaced because of the nursing shortage, decreased financial ability to hire adequate staff, and greatly increasing workloads. Staffing assignments should be evaluated to identify situations that contribute to sleep deprivation, and those situations should be corrected. Managers should be aware of the potential for accidents and consider increased risks for error when they schedule work shifts and call. Safety is a major concern for both patients and staff members, and simple, inexpensive solutions can counteract the risk of an accident occurring because of sleep deprivation. With some attention, sleep deprivation should not be a major problem in the OR.

NOTES

(1.) M A Hack et al, "Comparison of the effects of sleep deprivation, alcohol and obstructive sleep apnea (OSA) on simulated steering performance," Respiratory Medicine 95 (July 2001) 594-601.

(2.) J T Arnedt et al, "How do prolonged wakefulness and alcohol compare in the decrements they produce on a simulated driving task?" Accident Analysis & Prevention 33 (May 2001) 337-344.

(3.) R Smith-Coggins et al, Rotating shiftwork schedules: Can we enhance physician adaptation to night shifts?" Academic Emergency Medicine 4 (October 1997) 951-961.

(4.) J J Pilcher, A S Walters, "How sleep deprivation affects psychological variables related to college students' cognitive performance," Journal of American College Health 46 (November 1997) 121-126.

(5.) M Beaumont et al, "Slow release caffeine and prolonged (64-h) continuous wakefulness: Effects on vigilance and cognitive performance," Journal of Sleep Research 10 (December 2001) 265-276.

(6.) Y Harrison, J A Horne, "Sleep loss and temporal memory," Quarterly Journal of Experimental Psychology. A, Human Experimental Psychology 53 (February 2000) 271-279.

(7.) M Gonzalez-Ortiz et al, "Effect of sleep deprivation on insulin sensitivity and cortisol concentration in healthy subjects," Diabetes, Nutrition & Metabolism 13 (April 2000) 80-83.

(8.) M E McCarthy, W F Waters, "Decreased attentional responsivity during sleep deprivation: Orienting response latency, amplitude, and habituation," Sleep 20 (February 1997) 115-123.

(9.) Y Harrison, J A Horne, "Sleep deprivation affects speech," Sleep 20 (October 1997) 871-877.

10. A M Williamson, A M Feyer, "Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication," Occupational & Environmental Medicine 57 (October 2000) 649-655.

(11.) S K Howard et al, "Simulation study of rested versus sleep-deprived anesthesiologists," Anesthesiology 98 (June 2003) 1345-1355.

(12.) G H Kamimori et al, "Effect of three caffeine doses on plasma catecholamines and alertness during prolonged wakefulness," European Journal of Clinical Pharmacology 56 (November 2000) 537-544.

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