The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
James L, Elkins-Brown N, Wilson M, et al. Int J Nurs Stud. 2021;123:104041.
Many hospitals have adopted a 12-hour work shift for nurses and some studies have shown a resulting increase in burnout and decrease in patient safety. In this study, researchers assessed simulated nursing performance, cognition, and sleepiness in day nurses and night nurses who worked three consecutive 12-hour shifts. Overall results indicated nurses on both shifts mostly maintain their abilities on the simulated nursing performance assessment despite reporting increased sleepiness and fatigue. However there was more individual variation in cognition and some domains of performance.
NIOSH . NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.
Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;78:e35-e46.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Jones AM, Clark JS, Mohammad RA. Am J Health Syst Pharm. 2021;78:818-824.
Burnout has been a focus of numerous studies since the beginning of the COVID-19 pandemic; however, this is the first to focus on burnout and secondary traumatic stress (STS) among health system pharmacists. Nearly two thirds (65.3%) of respondents had a moderate to high likelihood of experiencing burnout and 51% had a high probability of STS. Due to the association between burnout and decreased patient safety, it is critical that health systems address pharmacist burnout appropriately.
Pharmacies are high-pressure environments generating conditions that undermine safety. This story highlights working conditions in chain pharmacies that cause concerns for pharmacists in their ability to prepare and dispense medications safely due to lack of appropriate staffing and time to do their jobs.
Whelehan DF, Algeo N, Brown DA. BMJ Leader. 2021;5:108-112.
Healthcare workers are facing occupational fatigue stemming from the COVID-19 pandemic (e.g., burnout, stress) as well as fatigue related to ongoing symptoms of the virus (“long COVID”). This article discusses preventive and proactive leadership strategies to address both types of fatigue, including screening for fatigue, providing reasonable accommodations for healthcare workers struggling with fatigue, stress mediation, and establishing organizational culture supporting sleep and rest.
The relationship between resident and physician duty hours and patient safety has been the focus of a lot of research. The relationship between nurse work schedules and patient safety is less explored. This review investigated the effect of extended or excessive nurse schedules on patient outcomes. Findings conclude that working more than 12 hours daily or more than 40 hours weekly may contribute to adverse patient outcomes. The authors recommend creating policies restricting nurse shifts to no more than 12 hours per day and 40 hours per week.
Rahman SA, Sullivan JP, Barger LK, et al. Pediatrics. 2021;147:e2020009936.
Reducing resident shift duration can improve resident health and patient safety. This study found that resident shifts limited to 16 hours can reduce performance impairment and medical errors, compared to extended work shifts (24+hours).
Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.
Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
González-Gil MT, González-Blázquez C, Parro-Moreno AI, et al. Intensive Crit Care Nurs. 2021;62:102966.
The COVID-19 pandemic has resulted in concerns about psychological and emotional well-being of health care professionals. In this cross-sectional study, critical care and emergency nurses in Spain report fears of COVID-19 infection, elevated workloads, higher nurse-to-patient ratios, communication struggles with management, and socio-emotional challenges in caring for their patients and themselves during the pandemic.
Schroers G, Ross JG, Moriarty H. Jt Comm J Qual Patient Saf. 2021;47:38-53.
Medication errors are a common source of patient harm. This systematic review synthesizing qualitative evidence concluded that nurses’ perceived causes of medication administration errors are multifactorial, interconnected, and stem from systems issues. Perceived causes included lack of medication knowledge, fatigue, complacency, heavy workloads, and interruptions.
Leviatan I, Oberman B, Zimlichman E, et al. J Am Med Inform Assoc. 2021;28:1074-1080.
Human factors, such as cognitive load, are main contributors to prescribing errors. This study assessed the relationship between medication prescribing errors and a physician’s workload, successive work shifts, and prescribing experience. The researchers reviewed presumed medication errors flagged by a computerized decision support system (CDSS) in acute care settings (excluding intensive care units) and found that longer hours and less experience in prescribing specific medications increased the risk of prescribing errors.
Watterson TL, Look KA, Steege LM, et al. Res Social Adm Pharm. 2021;17:1282-1287.
Fatigue has been linked to safety-related outcomes among many types of healthcare providers and settings. Using exploratory factor analysis, this study found physical and mental fatigue were the primary drivers of occupational fatigue in pharmacists. To increase safety, organizational interventions should strive to prevent burnout among pharmacists.
Elliott J, Williamson K. Radiography. 2020;26:248-253.
Extended work shifts for nurses and physicians have been linked to increased risk of errors. In this systematic review, the authors discuss the impact of shift work disorder on errors and safety implications for radiographers. Studies suggested a positive correlation between errors and increased mental and physical fatigue resulting from shift work or rapid shift rotation, however none of the identified studies focused specifically on radiology professionals.
Finn KM, Halvorsen AJ, Chaudhry S, et al. J Gen Intern Med. 2020;35:3205-3209.
This article reports on results from a 2017 survey of internal medicine residency program directors’ support for flexible work hours introduced by the Accreditation Committee on Graduate Medical Education (ACGME) based on trial results. Although the majority of programs supported the ACGME work hour flexibility, only one quarter of programs introduced longer work hours.
Di Simone E, Fabbian F, Giannetta N, et al. Eur Rev Med Pharmacol Sci. 2020;24:7058-7062.
Based on survey data of a sample of nurses, the authors identified a significant association between perceived risk of near miss medication errors and both poor sleep quality and short resting time after a night shift.
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8:639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.
Kolla BP, Coombes BJ, Morgenthaler TI, et al. J Gen Intern Med. 2020;36:51-54.
This observational study observed nonsignificant increases in patient safety incidents in the week following the transition into and out of daylight savings time (DST) over an eight-year period. The authors suggest policymakers and health system leadership evaluate risk mitigation strategies such as delayed shift start times during the transition to and from DST.
Patel AG, Pizzitola VJ, Johnson CD, et al. Radiology. 2020;297:374-379.
The authors analyzed CT interpretation errors committed by radiology fellows working off-hours over a four-year period and found that interpretation errors occurred more frequently at night and in the latter half of night assignments.
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