Joint Commission Issues Sentinel Event Alert on Healthcare Worker Fatigue

The Joint Commission yesterday issued a sentinel event alert highlighting the link between healthcare worker fatigue from long hours and adverse events.

The alert summarizes a number of studies on worker fatigue and patient safety and lists a number of problems that can result from inadequate amounts or quality of sleep of an extended period. These include:

• lapses in attention and inability to stay focused
• reduced motivation
• compromised problem solving
• confusion
• irritability
• memory lapses
• impaired communication
• slowed or faulty information processing and judgment
• diminished reaction time
• indifference and loss of empathy6

The alert then provides a list of actions healthcare organizations should take to minimize fatigue associated with long and consecutive shifts. These actions include but are not limited to assessing fatigue-related risks and hand-off processes; creating and implementing a fatigue management plan; educating staff on the impact of fatigue on patient safety; and providing opportunities for staff to express concerns regarding fatigue.

Related Articles on The Joint Commission:

Joint Commission Journal Features Kaiser Permanente's 6-Part Continuous Improvement Process
Joint Commission Proposes Patient Safety Goal to Reduce Overuse of Healthcare Services

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