Joint Commission Alert Recommends Fatigue Measures

Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety was created to help health care organizations address the risks of extended work days and cumulative days of extended work hours.

The Joint Commission's new Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety is a concise document recommending actions by health care organizations so they can address the risks of extended work days and cumulative days of extended work hours.

The organization posted the four-page document Dec. 14. It references studies that indicate errors, close calls, and occupational injuries rise among nurses who work shifts of 12 hours or longer, as well as higher patient safety and personal injury risks for residents who work recurring 24-hour shifts.

The commission accredits and certifies more than 19,000 health care organizations and programs nationwide. This alert advises organizations to conduct assessments of fatigue-related risks, assess patient hand-off procedures and processes to ensure they adequately protect patients, invite staff input into designing work schedules to minimize the potential for fatigue, implement a fatigue management plan, and educate staff about sleep hygiene and the effects of fatigue on patient safety.

The alert also recommends teamwork to support staffers who work extended hours, such as using a system of independent second checks for critical tasks or complex patients.

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