Dangers of Fatigue on Joint Commission Radar Screen

The Joint Commission issued a Sentinel Event Alert: Healthcare worker fatigue and patient safety on December 14, stating that: “The link between healthcare worker fatigue and adverse events is well documented, with a substantial number of studies indicating that the practice of extended work hours contributes to high levels of worker fatigue and reduced productivity.”

The evidence shows that fatigue increases the risk of adverse events, compromises patient safety, and increases risk to personal safety and well-being.” In the Sentinel Alert, the Joint Commission makes several recommendations to “help mitigate the risks of fatigue that result from extended work hours—and therefore, protect patients from preventable adverse outcomes.” The Alert also makes three safety culture recommendations:

The Alert also makes three safety culture recommendations:

  • Provide opportunities for staff to express concerns about fatigue. Support staff when appropriate concerns about fatigue are raised and take action to address those concerns;
  • Encourage teamwork as a strategy to support staff working extended work hours;
  • Consider fatigue as a potentially contributing factor when reviewing all adverse events.

The Joint Commission accredits and certifies more than 19,000 healthcare organizations and programs in the U.S.

The Sentinel Event Alert is a newsletter that identifies specific types of sentinel events, describes common underlying causes, and recommends steps to prevent future occurrences. Past Sentinel Alert topics have included medication errors, wrong-site surgery, blood transfusion errors, fatal falls, and intimidating behavior. Download the Sentinel Alert on fatigue here.

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