Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Nov 2007
Effects of health care provider work hours and sleep deprivation on safety and performance.
There has been increasing interest in the impact of resident-physician and nurse work hours on patient safety. The evidence demonstrates that work schedules have a profound effect on providers' sleep and performance, as well as on their safety and that of their patients. Nurses working shifts greater than 12.5 hours are at significantly increased risk of experiencing decreased vigilance on the job, suffering an occupational injury, or making a medical error. Physicians-in-training working traditional > 24-hour on-call shifts are at greatly increased risk of experiencing an occupational sharps injury or a motor vehicle crash on the drive home from work and of making a serious or even fatal medical error. As compared to when working 16-hours shifts, on-call residents have twice as many attentional failures when working overnight and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors that lead to a patient's death. ⋯ The weight of evidence strongly suggests that extended-duration work shifts significantly increase fatigue and impair performance and safety. From the standpoint of both providers and patients, the hours routinely worked by health care providers in the United States are unsafe. To reduce the unacceptably high rate of preventable fatigue-related medical error and injuries among health care workers, the United States must establish and enforce safe work-hour limits.
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Jt Comm J Qual Patient Saf · Nov 2007
Case ReportsUsing the rapid response system to provide better oversight of patient care processes.
The cross-disciplinary nature of patient care and medical emergency teams allows for identification of systemwide problems that might otherwise be perceived as isolated events.
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Jt Comm J Qual Patient Saf · Nov 2007
Improving the health care work environment: implications for research, practice, and policy.
Despite the gains to date, we need better understanding of practices for implementing and sustaining improvements in health care work environments and further study of organizational conditions affecting implementation of improvements. ⋯ Limiting work hours, improving schedules, and providing sleep hygiene training will help combat clinician fatigue. Hospital crowding can be reduced through systemwide improvement of patient flow and capacity management, coupled with management support, measurement, and reporting on crowding. Long-term solutions to nurse staffing shortfalls include process redesign to enhance efficiency. Improvement of organizational climate, human resource management, and interoccupational relations will also contribute to staff retention. Evidence-based enhancements to patient rooms and other physical features in hospitals contribute directly to safety and quality and also affect staff performance. POLICY: Landrigan and his colleagues call for external restrictions on residents' work shifts. Clarke examines prospects for mandated nursing-staff ratios. Public reporting on staffing, crowding, and other risks may incent change. Reporting and pay for performance require standardized measures of targeted conditions. Organizations promoting care quality can help spread safe work practices; they can also support collaborative learning and other strategies that may enhance implementation of improvements in work environments.
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Approximately one third of hospitals in the United States report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the emergency department (ED). In a recent national survey, 40% of hospital leaders viewed ED crowding as a symptom of workforce shortages. Many health systems are implementing a variety of strategies to improve flow and reduce crowding. ⋯ Health systems can take tangible, immediate steps to improve flow and reduce crowding. Efforts would be enhanced by more controlled trials of existing strategies in the context of uniform performance measures.