Throughout my career, I have found the topic of surgeon fatigue and sleep deprivation to be intriguing and important. Unfortunately, the opinions of experts on this topic tend to gravitate from one extreme to the other. For example, a study in The Joint Commission Journal on Quality and Patient Safety found evidence to support the view that extended work shifts significantly increase fatigue and impair performance and safety,* whereas other research reported in the surgical literature finds that fatigue has a minimal effect on the development of patient complications. I believe a balanced and reasonable approach is needed in addressing this issue.
Many factors can contribute to surgeon fatigue, including insufficient staffing, excessive workloads, extended workdays, and cumulative days of heavy work hours. Fatigue can be dangerous, causing lapses in attention or inability to stay focused, reduced motivation, compromised problem-solving skills, confusion, irritability, memory lapses, impaired communication, slowed or faulty information processing and judgment, diminished reaction time, and indifference and loss of empathy. All of these factors can affect the surgical team, directly or indirectly, resulting in potentially serious or even deadly consequences.
Fatigue in a culture of safety
Addressing fatigue requires leadership support and a culture of safety. Such a culture embraces the concept of reporting and addressing any factor that compromises safety. When an institution’s leadership supports a culture of safety, staff members know that their concerns will be heard and taken seriously. To aid in developing such a culture, The Joint Commission’s Sentinel Event Alert #48 from December 2011 outlines actions for leadership to consider, including the following:†
- Assess the organization for fatigue-related risks
- Assess the organization’s hand-off processes and procedures, given that hand-offs occur at a time when staff are more likely to be fatigued
- Provide opportunities for staff to establish schedules that minimize the risk of fatigue
- Create and implement a fatigue management plan that incorporates scientific strategies for mitigation of fatigue
- Educate staff on sleep hygiene and recognition of fatigue
- Provide opportunities for staff to express concerns about fatigue
- Encourage teamwork as a strategy to support staff who work extended shifts
- Consider fatigue as a potential contributing factor when reviewing all adverse events
In addition to establishing a culture of safety, it is critical to provide proper training to identify the effects of fatigue on patient safety. If surgeons are trained to understand how fatigue manifests and affects their mental and physical capabilities, they can use this knowledge to determine whether to take a break or nap, postpone an operation, or carry it out with extra help. Disclosure of fatigue to a patient and obtaining consent to proceed is not an option; it is morally untenable to ask a patient permission to proceed if and when the surgeon believes that doing so could harm the individual.
The American College of Surgeons and The Joint Commission have independently devoted substantial resources to ensuring that surgeons perform operations as safely as possible. Both organizations have developed statements on fatigue and have offered strategies for recognizing and managing its effects.†‡ These recommendations include suggestions on appropriate ways to monitor fatigue as well as strategies to overcome problems that may arise from rescheduling a procedure.
Health care organizations should invite staff to offer input on designing work schedules and creating and implementing a fatigue management plan that includes strategies that are aligned with the needs of the institution and the patient population it serves.
Although these strategies will differ from institution to institution depending on location, population demographics, size, geography, availability of other surgeons in the area, and other factors, surgeons and other health care professionals should work with the leadership of the hospital to develop suitable strategies to prevent surgeon fatigue and sleep deprivation. As surgeons, we owe it to our patients.
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily represent the official views of The Joint Commission or the American College of Surgeons.
*Lockley SW, Barger LK, Ayas NT, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. The Joint Commission Journal on Quality and Patient Safety. 2007;33(11):7-18. Available at: www.jointcommission.org/JQPS_11_07/. Accessed May 1, 2015.
†The Joint Commission. Sentinel Event Alert #48: Health care worker fatigue and patient safety. December 2011. Available at: www.jointcommission.org/assets/1/18/sea_48.pdf. Accessed May 1, 2015.
‡The American College of Surgeons. Statement on peak performance and management of fatigue. Bull Am Coll Surg. 2014;99(8):53-54. Available at: bulletin.facs.org/2014/08/statement-on-peak-performance-and-management-of-fatigue/. Accessed May 18, 2015.