Ann E. Rogers PhD, RN, FAAN Associate Professor University of Pennsylvania School of Nursing

1. Staff Nurse Fatigue and Patient Safety • Ann E. Rogers PhD, RN, FAAN • Associate Professor • University of Pennsylvania School of Nursing

2. Case Study

3. Case Study 1 On July 4, 2006, a nurse worked a double shift that ended at midnight. The nurse had volunteered for the shifts some time prior to coming to work on July 4 and had arranged to sleep at the hospital following the shifts because she began another scheduled 8-hour shift on the Birthing Unit, at 7:00 a.m. on July 5th.

4. Case Study 1 (cont.) That morning the nurse made a series of errors that resulted in the death of a patient 1) she failed to place the armband on the patient’s wrist 2) at 11:30 pm she removed the patient’s medications from the pxyis along with the epidural medications (a combination of bupivacaine and fentanyl) that she thought might be needed later and placed them on a counter in the birthing room 3) after starting an IV on her patient at 12:06, grabbed the bag of what she thought was penicillin and added it to the IV without checking the bag, scanning the patients wristband or using the bar-code administration system

5. Case Study 1(cont.) The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code.

6. Case Study 1(cont.) The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non-pharmacist dispensing and possessing/illegally obtaining a prescription)

7. Case Study 1(cont.) The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non-pharmacist dispensing and possessing/illegally obtaining a prescription) License suspended for 9 months and no longer allowed to work any OB/birthing area, ICU, or critical care areas, or any shift >12 hours

8. Could it Happen Again?

9. Goal of Study • To determine if the extended shifts and overtime worked by full-time hospital staff nurses had an adverse effect on patient safety

10. 895 participants were predominately female (93%),middle-aged (mean age 44.5 ± 8.3,range 22-66), and Caucasian (82%) Worked at least 36 hours/week Were unit based and employed by a hospital Were members of the American Association of Critical Care Nurses or the American Nurses Association Participants

11. Instruments • Demographic Questionnaire • Logbooks (2) • 28-day record of sleep/wake patterns, work hours, difficulties remaining alert on duty and errors

12. The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

13. The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

14. Over one third of the shifts were scheduled for 12.5 hours or longer, and 43% of the shifts exceeded 12.5 consecutive hours. There were 44 shifts scheduled for ≥ 20 consecutive hours, and 123 shifts where nurses worked ≥ 20 consecutive hours. Shift Durations

15. % of Shifts Hours Scheduled and Actual Shift Durations (ANA Sample)

16. Hours Scheduled and Actual Shift Durations (ANA Sample) % of Shifts

17. Longest shiftwas 23 hrs, 50 minutes Hours Scheduled and Actual Shift Durations (ANA Sample) % of Shifts

18. % of Shifts Hours Scheduled and Actual Shift Durations (AACN Sample)

19. % of Shifts Longest shiftwas 23 hrs, 40 minutes Hours Scheduled and Actual Shift Durations (AACN Sample)

20. Overtime • Working longer than scheduled was normal • Nurses rarely left work at the end of their scheduled shift (19%, 13%) • They averaged almost an hour (55 minutes, 49 minutes) extra work/day • Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample

21. Overtime • Working longer than scheduled was normal Nurses rarely left work at the end of their scheduled shift (19%, 13%) • They averaged almost an hour (55 minutes, 49 minutes) extra work/day • Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample • The frequency of mandatory overtime varied • ANA Sample 360 shifts (7%) were mandated and 143 voluntary overtime shifts (3%) were coerced • AACN Sample 263 shifts (16.5%) were mandated and 152 voluntary overtime shifts (12.3%) were coerced

22. Errors

23. Errors • Just under one-third of the participants reported making an error during the data-gathering period. • Near errors were reported by one third of the participants.

24. Association of Work Duration and Errors * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

25. Association of Work Duration and Errors * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

26. Association of Errors with Overtime (ANA sample) * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

27. Association of Errors with Overtime (ANA sample) * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

28. Sleepy Nurses

29. Difficulties Remaining Alert on Duty Were Common

30. Difficulties Remaining Alert on Duty Were Common (cont.)

31. No. of Shifts Time of Day Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)

32. No. of Shifts Time of Day Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)

33. Long Work Hours Adversely Affect Vigilance (AACN Sample)

34. Long Work Hours Adversely Affect Vigilance (AACN Sample)

35. Long Work Hours Adversely Affect Vigilance (AACN Sample)

36. Sleepy nursescan endangerthe general public

37. Drowsy Driving Was Common

38. Drowsy Driving Wasn’t Just a One Time Occurrence • number of times that drowsy driving was reported ranged from 1-20 times • only 21% of those who reported struggling to stay awake driving home, reported it only once • just under 1/4 of participants reported struggling to stay awake driving home from work at least 75% of the time • 30 nurses (5%) reported difficulties staying awake driving home after every shift they worked

39. Factors Associated with Drowsy Driving • Working 12-hour shifts doubled the risk of drowsy driving • Longer commutes • Working at night (at least 6 hours between 2200 and 0600) nearly quadrupled the risk of struggling to stay awake driving home

40. Nurses Who Struggled To Stay Awake Driving Home Obtained Less Sleep

41. Acknowledgements • David Dinges PhD • Wei-Ting Hwang PhD • Linda Scott PhD, RN American Association of Critical Care Nurses American Nurses Association Agency for Healthcare Research and Quality (R01 HS11963) American Nurses Foundation Grant (Scott)