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Comments on Joint Commission’s Draft 2008 Patient Safety Goal on Health Care Worker Fatigue

Jennifer Hoppe
Division of Standards and Survey Methods
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

Dear Ms. Hoppe:

We are writing to express our concerns regarding the Joint Commission’s Draft 2008 Patient Safety Goal on health care worker fatigue (Goal 18).  Given the strength of the data on this issue, we simply cannot understand why the Joint Commission’s draft is so weak and non-specific with respect to this well-documented cause of harm to patients in hospitals.

The growth of data establishing the dangers of fatigue for both patient and worker health is reflected in the expansion of the Joint Commission Rationale for this Goal from four lines in last year’s unadopted draft to 13 in the current draft.  Yet, even this understates the significance of the rapidly accumulating scientific knowledge on the dangers of fatigue. 

The Institute of Medicine report “To Err is Human” has generated a veritable cottage industry of companies selling technological fixes for problems such as the use of interacting drugs.  Most of these problems have twin characteristics: a. they represent a distinct minority of iatrogenic illnesses; and b. their solutions, however rational, have not been completely proved.

In contrast, the area of fatigue is distinguished by a gold-standard randomized, controlled trial proving the efficacy of reduced work hours in lowering medical error rates.  Moreover, the efficacy in that trial was demonstrated against all types of medical errors, including some that are now the subject of the aforementioned technological fixes.  In the randomized trial, researchers demonstrated that serious nonintercepted medical errors could be reduced by 36 percent if extended work shifts (greater than 16 hours) in the intensive care unit were abandoned.[1]   This finding was confirmed in a survey of 2737 interns, in which the odds of a fatigue-related error that led to an adverse patient outcome were increased nine-fold for those working one to four extended shifts per month and seven-fold for those working more than four extended shifts, compared to those not working such shifts.  Both findings were statistically significant.  The odds of an error leading to patient death were increased three- to four-fold, respectively, the latter statistically significant.[2]

The risks of resident fatigue are not confined to patients.  In the survey cited above, the odds of daytime percutaneous injuries were 61 percent higher for those working extended shifts compared to those working nonextended ones.[3]   In this same survey, house officers driving after an extended shift were 2.3 times as likely to report a motor vehicle accident as those who had not worked such a shift.[4]  The safety of workers, in addition to the safety of patients, is a legitimate goal for the Joint Commission.  In this case, one intervention, reduced work hours, is likely to be effective against both.

Due to the vagueness of the Joint Commission’s goals, many residency programs are likely to refer to their claimed implementation of the work-hour standards of the Accreditation Council for Graduate Medical Education (ACGME) as evidence that they are “scheduling work hours and on-call periods to minimize fatigue,” as required by Safety Goal 18.  In the first place, the ACGME standards are far too lax, hiding behind such sleights of hand as averaging, lengthy periods for hand-offs to incoming staff, and program exemptions to permit work hours considerably in excess of what the standards appear to allow.[5]  They are completely inconsistent with emerging data in the science of sleep loss,[6] which demonstrate decreases in medical errors[1] and attentional failures[7] in 16-hour shifts compared to conventional ones.  In the second place, compliance with even the ACGME proposals has been lax, at best.  In an independent study of intern work hours in the year following implementation of the ACGME guidelines, 85 percent of all residency programs had at least one violation.[8]  On a monthly basis, 44 percent of interns experienced such violations, most commonly of the 30-hour limit on shift length.

If the Joint Commission is serious about reducing medical errors, it will lay heavy emphasis on the reduction of work hours for residents, as well as other clinical personnel.  Few of the Safety Goals will affect medical errors of all kinds and fewer still, if any, are supported by a randomized, controlled trial.  As mentioned, work-hour reduction meets both criteria.  The Safety Goals should reflect this strong evidence base by adding greatly enhanced specificity: total hour limits, shift length limits, mandatory time away from work, etc.  Anything less will permit a significant fraction of serious medical errors to continue, even as the Joint Commission has at its disposal the means to greatly reduce them.

Yours sincerely,

Peter Lurie, M.D., M.P.H.
Deputy Director
Public Citizen’s Health Research Group

Sidney M. Wolfe, M.D.
Public Citizen’s Health Research Group

[1] Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine. 2004;351:1838-48.

[2] Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events and attentional failures. PLoS Medicine 2006;3:e487. doi:10.1371/journal.pmed.0030487.

[3] Ayas NT, Barger LK, Hashimoto DM, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. Journal of the American Medical Association 2006;296:1055-62.

[4] Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine. 2005;352:125-34.

[5] See, for example, table summarizing various work-hour proposals at https://www.citizen.org/sites/default/files/1633attachment.pdf

[6] PhilibertI. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep 2005;28:1392-1402.

[7] Lockley S. W., Cronin J. W., Evans E. E., et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. New England Journal of Medicine 2004;351:1829-37.

[8] Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns’ compliance with Accreditation Council for Graduate Medical Education work-hour limits. Journal of the American Medical Association 2006;296:1063-70.