How Physician Exhaustion Impacts Patient Safety

Portrait of a female doctor/surgeon feeling down, exhausted, frustrated, very tired, .... on white background

By: Michael Ramsay MD, FRCA, chief executive officer at the Patient Safety Movement Foundation

Medical errors have historically been the third leading cause of preventable death in the U.S. Since 2000, when “To Err is Human: Building a Safer Health System” was published, more attention has been given to this critical topic. Over the years, many patient safety organizations were formed to address this problem together with the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention, as hospital acquired infections continued to be a major cause of these deaths. 

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While progress was made, COVID-19 complicated healthcare and resulted in more unsafe care – putting healthcare workers and patients at risk. During the pandemic, frontline workers experienced increased stress and demands as they had to treat COVID-19 patients. It became obvious during this time that we cannot have patient safety without healthcare worker safety. In fact, according to a recent report, the major advances that had occurred in patient safety over the previous five years were almost totally reversed when the pandemic struck. Central venous catheter and urinary catheter infections that had decreased in five years by 31% went up as stress, fatigue and sleep deprivation increased. 

Even prior to the pandemic, one area of health care that has been difficult to control is physician fatigue. Emergencies occur at any time and physicians are often expected to work long hours on complicated situations. As much training as they undergo, physicians are human beings. While humans are a phenomenal physiological machine, they are prone to make errors and these errors increase when there is fatigue, caused by sleep deprivation, overwork and stress. 

The recent shift from standard time to daylight saving time – which sprung us forward and took an hour of sleep away from everyone – created an opportunity for healthcare systems to ensure processes are in place to support physicians and ensure errors do not occur. The effect on health care professionals by the loss of a critical hour of sleep may well have a deleterious effect on those already stressed and fatigued. A recent study from the Mayo Clinic examined this effect on the number of safety-related incidents reported in the week following the institution of daylight saving time. They found an 18.7% increase of patient safety reported events. This surge on top of the prolonged COVID-19 pandemic increases sets us back approximately a decade in patient safety and healthcare worker safety.

Here are three areas to examine at your healthcare facility to help reduce medical errors resulting from frontline worker stress and fatigue. 

  • Medication Errors: Medication errors are major causes of patient harm and death. These preventable adverse events can result from:
    • Wrong medication
    • Wrong dose
    • Wrong route
    • Wrong time
    • Wrong patient
    • Wrong documentation of medication

To minimize medication errors, the healthcare worker should understand and be able to answer what medication is being given and why at the time of administration. In addition, healthcare workers should hold themselves to high standards during the process to minimize other potential issues, such as following proper hand washing protocols to reduce hospital acquired infections.      This is especially important during a time change and shift change, as everyone in your health system needs to be on the same page about monitoring and administering medications. 

  • Hand Off Errors: Miscommunication is another major cause of errors in hospitals. Especially at the end of a long shift, it can be easy to let something slip through the cracks. But adoption of a clear and consistent communication strategy – such as I-PASS or SBAR – can help reduce ineffective hand-offs by about 60% and decrease preventable adverse events by 30%. Therefore, it is important to establish shared expectations for communication across the system and hold all frontline workers accountable. A well-executed hand off should occur in a dedicated space without distractions where both parties can be focused. In this instance, both parties play a critical role. The sender is responsible for providing concise, specific and well-organized information and the receiver should synthesize and repeat it back for accuracy and ask clarifying questions if needed. 
  • Diagnostic Errors: When stressed and fatigued, physicians are at increased risk of making diagnostic errors – whether wrong, missed or delayed. Implementing a checklist that physicians can reference when making a diagnosis can help ensure that they are taking the time to consider all options. In addition, having plans in place to involve patients and family members at the time of care is important to ensure that physicians have accurate information available to make an informed diagnosis. Engaging with a patient advocate can help improve communication between doctors and patients to keep all parties accountable. 

While managing physician stress and fatigue needs to become the top priority, ensuring your health system is prepared to support areas that are most missed due to fatigue is equally important. The Patient Safety Movement Foundation provides evidence-based best practice lists or Actionable Patient Safety Solutions (APSS). These provide healthcare systems a free resource to help engage the staff to improve management of various conditions. These are simple to use checklists that improve adoption and have been created by multidisciplinary workgroups,      including leading                    medical experts globally.   

ABOUT THE AUTHOR: Michael Ramsay is the CEO at the Patient Safety Movement Foundation.  The Patient Safety Movement Foundation is a global non-profit with a vision to eliminate preventable patient harm and death across the globe by 2030. It provides free evidence-based  Actionable Patient Safety Solutions  to help health systems improve their care. Prior to this role, he was the chair-emeritus of the Department of Anesthesiology and Pain Management at Baylor University Medical Center and past president of the Baylor Scott & White Research Institute. He was part of a major organ transplantation team that frequently transplanted organs during the night that gave him close insight into the effects of fatigue. 

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