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Sentinel Event Alert. December 14, 2011;(48):1-4. (addendum May 14, 2018).

The Joint Commission issues sentinel event alerts to emphasize pressing safety issues and provide guidelines for organizations on how to address them. The link between health care worker fatigue and patient safety has been established in seminal studies, which have demonstrated that the risk of error increases when nurses work more than 12 hours per shift and when resident physicians work more than 16 consecutive hours. In response to these data, the Accreditation Council for Graduate Medical Education (ACGME) further restricted resident duty hours in 2011. This alert calls on hospitals to design work schedules to minimize fatigue risks, monitor the safety of handoffs, and provide education for clinicians on fatigue management strategies. The combination of the ACGME regulations and this sentinel event alert provides a powerful incentive for teaching hospitals and residency programs to harmonize efforts around minimizing the risk of fatigue-related complications.