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SOURCE Pennsylvania Patient Safety Authority
Thirty-seven events were reported as Serious Events (events that cause harm) and four of the harmful events resulted in patient death
HARRISBURG, Pa., June 5, 2014 /PRNewswire-USNewswire/ -- Healthcare worker fatigue is cited as a contributing factor in over 1,600 events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) to the Pennsylvania Patient Safety Authority with 37 reported as harmful events including four patient deaths, according to an article from the June Pennsylvania Patient Safety Advisory released today.
Medication errors (62.1%, n=995) and errors related to a procedure, treatment or test (26%, n=422) made up 88.5% of all events reported with healthcare worker fatigue as a contributing factor. The data query found 1,601 events identified between June 2004 and August 2013; 1,564 events (97.7%) were reported as Incidents or near misses that did not result in harm to the patient.
"Recent literature shows that one of the first efforts made to reduce events related to fatigue was target limiting the hours worked," Theresa V. Arnold, DPM, manager of clinical analysis for the Pennsylvania Patient Safety Authority said. "However, further study suggests a more comprehensive approach is needed, as simply reducing hours does not address fatigue that is caused by disruption in sleep and extended work hours."
Fatigue can be described as an overwhelming sense of tiredness, lack of energy and feeling of exhaustion associated with impaired physical and/or cognitive functioning, Arnold added.
"In studies conducted with nurses, it was shown that working a 12-hour work shift or working overtime is associated with difficulties staying awake while on duty, reduced sleep times, and nearly triple the risk of making an error," Arnold said. "The most significant error risk observed was when nurses worked 12.5 hours or longer."
"Many hospitals have adopted 12-hour shifts as the norm and it is a similar choice among nurses who want to limit the number of days they work in a week, but research on the 12-hour shift and patient safety needs further review," Arnold added.
PA-PSRS allows facility reporters to select fatigue as a contributing factor to an event report.
"The top five locations in which events occurred were the medical-surgical unit, emergency department, pharmacy, general medical ward and the laboratory," Arnold said. "The most common medication errors made involving healthcare worker fatigue were wrong dose given; dose omission and extra dose given and the most common errors related to a procedure, treatment or test were laboratory errors, and other miscellaneous errors, radiology or imaging problems and surgical invasive procedure problems."
Healthcare organizations are using some mitigating practices to combat workplace fatigue and patient harm. A lot can be learned from other industries and countries that are using more developed fatigue and risk management systems (FRMSs) as a method of reducing this risk, Arnold added.
For more information about healthcare worker fatigue in Pennsylvania go to the June Pennsylvania Patient Safety Advisory article, "Healthcare Worker Fatigue: Current Strategies for Prevention," at www.patientsafetyauthority.org.
The Authority's 2014 June Advisory contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights of the 2014 June Advisory include:
For the complete 2014 June Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.
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