1. Ann E. Rogers PhD, RN, FAAN Associate Professor University of Pennsylvania School of Nursing Ann E. Rogers PhD, RN, FAAN Associate Professor University of Pennsylvania School of Nursing Staff Nurse Fatigue and Patient Safety

2. Case Study

3. On July 4, 2006, a nurse worked a double shift that ended at midnight. The nurse had volunteered for the shifts some time prior to coming to work on July 4 and had arranged to sleep at the hospital following the shifts because she began another scheduled 8-hour shift on the Birthing Unit, at 7:00 a.m. on July 5th. Case Study 1

4. That morning the nurse made a series of errors that resulted in the death of a patient 1) she failed to place the armband on the patient’s wrist 2) at 11:30 pm she removed the patient’s medications from the pxyis along with the epidural medications (a combination of bupivacaine and fentanyl) that she thought might be needed later and placed them on a counter in the birthing room 3) after starting an IV on her patient at 12:06, grabbed the bag of what she thought was penicillin and added it to the IV without checking the bag, scanning the patients wristband or using the bar-code administration system That morning the nurse made a series of errors that resulted in the death of a patient 1) she failed to place the armband on the patient’s wrist 2) at 11:30 pm she removed the patient’s medications from the pxyis along with the epidural medications (a combination of bupivacaine and fentanyl) that she thought might be needed later and placed them on a counter in the birthing room 3) after starting an IV on her patient at 12:06, grabbed the bag of what she thought was penicillin and added it to the IV without checking the bag, scanning the patients wristband or using the bar-code administration system Case Study 1 (cont.)

5. The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. Case Study 1(cont.)

6. The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non- pharmacist dispensing and possessing/illegally obtaining a prescription) The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non- pharmacist dispensing and possessing/illegally obtaining a prescription) Case Study 1(cont.)

7. The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non- pharmacist dispensing and possessing/illegally obtaining a prescription) License suspended for 9 months and no longer allowed to work any OB/birthing area, ICU, or critical care areas, or any shift >12 hours The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non- pharmacist dispensing and possessing/illegally obtaining a prescription) License suspended for 9 months and no longer allowed to work any OB/birthing area, ICU, or critical care areas, or any shift >12 hours Case Study 1(cont.)

8. Could it Happen Again?

9. To determine if the extended shifts and overtime worked by full-time hospital staff nurses had an adverse effect on patient safety Goal of Study

10. 895 participants were predominately female (93%), middle-aged (mean age 44.5 ± 8.3,range 22- 66), and Caucasian (82%) Worked at least 36 hours/week Were unit based and employed by a hospital Were members of the American Association of Critical Care Nurses or the American Nurses Association 895 participants were predominately female (93%), middle-aged (mean age 44.5 ± 8.3,range 22- 66), and Caucasian (82%) Worked at least 36 hours/week Were unit based and employed by a hospital Were members of the American Association of Critical Care Nurses or the American Nurses Association Participants

11. Demographic Questionnaire Logbooks (2) 28-day record of sleep/wake patterns, work hours, difficulties remaining alert on duty and errors Demographic Questionnaire Logbooks (2) 28-day record of sleep/wake patterns, work hours, difficulties remaining alert on duty and errors Instruments

12. The majority of nurses no longer work traditional 8 hour day, evening, or night shifts ANA Sample No. of Nurses (%) AACN Sample No. of Nurses (%) Total Sample No. of Nurses (%) 8 hours 150 (38.3%) 60 (11.9%) 210 (23.4%) 12 hours 230 (58.7%) 436 (86.2%) 668 (74.2%) Other 12 (3.1%) 10 (1.9%) 22 (2.4%)

13. The majority of nurses no longer work traditional 8 hour day, evening, or night shifts ANA Sample No. of Nurses (%) AACN Sample No. of Nurses (%) Total Sample No. of Nurses (%) 8 hours 150 (38.3%) 60 (11.9%) 210 (23.4%) 12 hours 230 (58.7%) 436 (86.2%) 668 (74.2%) Other 12 (3.1%) 10 (1.9%) 22 (2.4%)

14. Shift Durations Over one third of the shifts were scheduled for 12.5 hours or longer, and 43% of the shifts exceeded 12.5 consecutive hours. There were 44 shifts scheduled for ≥ 20 consecutive hours, and 123 shifts where nurses worked ≥ 20 consecutive hours. Over one third of the shifts were scheduled for 12.5 hours or longer, and 43% of the shifts exceeded 12.5 consecutive hours. There were 44 shifts scheduled for ≥ 20 consecutive hours, and 123 shifts where nurses worked ≥ 20 consecutive hours.

15. Scheduled and Actual Shift Durations (ANA Sample) Hours % of Shifts % of Shifts

16. % of Shifts % of Shifts Scheduled and Actual Shift Durations (ANA Sample) Hours

17. % of Shifts % of Shifts Scheduled and Actual Shift Durations (ANA Sample) Hours Longest shift was 23 hrs, 50 minutes

18. Hours % of Shifts % of Shifts Scheduled and Actual Shift Durations (AACN Sample)

19. Hours % of Shifts % of Shifts Scheduled and Actual Shift Durations (AACN Sample) Longest shift was 23 hrs, 40 minutes

20. Working longer than scheduled was normal Nurses rarely left work at the end of their scheduled shift (19%, 13%) They averaged almost an hour (55 minutes, 49 minutes) extra work/day Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample Working longer than scheduled was normal Nurses rarely left work at the end of their scheduled shift (19%, 13%) They averaged almost an hour (55 minutes, 49 minutes) extra work/day Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample Overtime

21. Working longer than scheduled was normal Nurses rarely left work at the end of their scheduled shift (19%, 13%) They averaged almost an hour (55 minutes, 49 minutes) extra work/day Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample The frequency of mandatory overtime varied ANA Sample 360 shifts (7%) were mandated and 143 voluntary overtime shifts (3%) were coerced AACN Sample 263 shifts (16.5%) were mandated and 152 voluntary overtime shifts (12.3%) were coerced Working longer than scheduled was normal Nurses rarely left work at the end of their scheduled shift (19%, 13%) They averaged almost an hour (55 minutes, 49 minutes) extra work/day Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample The frequency of mandatory overtime varied ANA Sample 360 shifts (7%) were mandated and 143 voluntary overtime shifts (3%) were coerced AACN Sample 263 shifts (16.5%) were mandated and 152 voluntary overtime shifts (12.3%) were coerced Overtime

22. Errors

23. Just under one-third of the participants reported making an error during the data- gathering period. Near errors were reported by one third of the participants. Just under one-third of the participants reported making an error during the data- gathering period. Near errors were reported by one third of the participants.

24. Association of Work Duration and Errors Association of Work Duration and Errors * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs Work Duration (hours) ANA Sample*AACN Sample No. Shifts (%) No. shifts with at least one error (%) OR (p= value) No. Shifts (%) No. shifts with at least one error (%) OR (p= value) ≤ 8.5 771 (14.4%) 12 (1.6%) 1.0 543 (9%) 11 (2%) 1.0 > 8.5, < 12.5 2484 (46.8%) 77 (3.1%) 1.85 (0.06) 1720 (29%) 46 (3%) 1.42 (0.304) ≥ 12.5 2057 (38.9%) 103 (5%) 3.29 (0.0001) 3748 (62%) 146 (4%) 1.94 (0.028) Total53121926011203

25. Association of Work Duration and Errors Association of Work Duration and Errors * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs Work Duration (hours) ANA Sample*AACN Sample No. Shifts (%) No. shifts with at least one error (%) OR (p= value) No. Shifts (%) No. shifts with at least one error (%) OR (p= value) ≤ 8.5 771 (14.4%) 12 (1.6%) 1.0 543 (9%) 11 (2%) 1.0 > 8.5, < 12.5 2484 (46.8%) 77 (3.1%) 1.85 (0.06) 1720 (29%) 46 (3%) 1.42 (0.304) ≥ 12.5 2057 (38.9%) 103 (5%) 3.29 (0.0001) 3748 (62%) 146 (4%) 1.94 (0.028) Total53121926011203

26. * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs Association of Errors with Overtime (ANA sample) Association of Errors with Overtime (ANA sample) Work Duration (hr) Overtime No. of Shits ≥ 1 error (%) OR (p-value) ≤ 8.5 No8/377 (2.1%)1.00 Yes64/2075 (3.1%)1.34 (0.42) > 8.5, <12.5 No6/246 (2.4%)1.00 Yes36/937 (3.8%)1.53 (0.36) ≥ 12.5 No6/360 (1.7%)1.0 Yes70/1263 (5.5%)3.26 (0.005) Total191/5258

27. Work Duration (hr) Overtime No. of Shits ≥ 1 error (%) OR (p-value) ≤ 8.5 No8/377 (2.1%)1.00 Yes64/2075 (3.1%)1.34 (0.42) > 8.5, <12.5 No6/246 (2.4%)1.00 Yes36/937 (3.8%)1.53 (0.36) ≥ 12.5 No6/360 (1.7%)1.0 Yes70/1263 (5.5%)3.26 (0.005) Total191/5258 * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs Association of Errors with Overtime (ANA sample) Association of Errors with Overtime (ANA sample)

28. Sleepy Nurses

29. Difficulties Remaining Alert on Duty Were Common Difficulties Remaining Alert on Duty Were Common ANA Sample No. Nurses (%) AACN Sample No. Nurses (%) Reported at least on episode of struggling to stay awake during the shift 196 (60.8%)324 (64.4%) Reported at least one episode of falling asleep on duty 86 (21.9%)66 (13.0%)

30. Difficulties Remaining Alert on Duty Were Common (cont.) Difficulties Remaining Alert on Duty Were Common (cont.) No. Shifts (%) ANA Sample No. Shifts (%) AACN Sample Reported struggling to stay awake during shift 1068 (20.3%)1217 (20.1%) Reported falling asleep on duty 269 (5.1%)180 (3.0%)

31. Time of Day No. of Shifts No. of Shifts Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)

32. Time of Day No. of Shifts No. of Shifts Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)

33. Work Duration (hours) Struggling to Stay Awake on Duty Fell Asleep on Duty No. shifts (%)OR (p-value)No. Shifts (%)OR ( p-value) ≤ 8.577 (14%)1.04 (0.7%)1.0 > 8.5, <12.5279 (16%)1.1 ( 0.695)30 (1.8%)1.9 (0.043) ≥ 12.5847 (23%)1.15 (0.007)44 (3.9%)2.40 (0.014) Total1203178 Long Work Hours Adversely Affect Vigilance (AACN Sample)

34. Work Duration (hours) Struggling to Stay Awake on Duty Fell Asleep on Duty No. shifts (%)OR (p-value)No. Shifts (%)OR ( p-value) ≤ 8.577 (14%)1.04 (0.7%)1.0 > 8.5, <12.5279 (16%)1.1 ( 0.695)30 (1.8%)1.9 (0.043) ≥ 12.5847 (23%)1.15 (0.007)44 (3.9%)2.40 (0.014) Total1203178 Long Work Hours Adversely Affect Vigilance (AACN Sample)

35. Work Duration (hours) Struggling to Stay Awake on Duty Fell Asleep on Duty No. shifts (%)OR (p-value)No. Shifts (%)OR ( p-value) ≤ 8.577 (14%)1.04 (0.7%)1.0 > 8.5, <12.5279 (16%)1.1 ( 0.695)30 (1.8%)1.9 (0.043) ≥ 12.5847 (23%)1.15 (0.007)44 (3.9%)2.40 (0.014) Total1203178 Long Work Hours Adversely Affect Vigilance (AACN Sample)

36. Sleepy nurses can endanger the general public

37. ANA SampleAACN Sample No. nurses reporting ≥ 1 episode of drowsy driving 263 (66.9%)331 (65.9%) No. of shifts with drowsy driving 1281 (24.6%)1639 (27.5%) Drowsy Driving Was Common

38. number of times that drowsy driving was reported ranged from 1-20 times only 21% of those who reported struggling to stay awake driving home, reported it only once just under 1/4 of participants reported struggling to stay awake driving home from work at least 75% of the time 30 nurses (5%) reported difficulties staying awake driving home after every shift they worked number of times that drowsy driving was reported ranged from 1-20 times only 21% of those who reported struggling to stay awake driving home, reported it only once just under 1/4 of participants reported struggling to stay awake driving home from work at least 75% of the time 30 nurses (5%) reported difficulties staying awake driving home after every shift they worked Drowsy Driving Wasn’t Just a One Time Occurrence

39. Working 12-hour shifts doubled the risk of drowsy driving Longer commutes Working at night (at least 6 hours between 2200 and 0600) nearly quadrupled the risk of struggling to stay awake driving home Working 12-hour shifts doubled the risk of drowsy driving Longer commutes Working at night (at least 6 hours between 2200 and 0600) nearly quadrupled the risk of struggling to stay awake driving home Factors Associated with Drowsy Driving

40. Nurses Who Struggled To Stay Awake Driving Home Obtained Less Sleep ANA SampleAACN Sample Drowsy Drivers Mean sleep duration (hrs) Median sleep duration (hrs) 6.37 ± 2.01 6.5 6.3 ± 2.10 6.2 Alert Drivers Mean sleep duration (hrs) Median sleep duration (hrs) 6.89 ± 1.63 6.98 6.77 ± 1.65 6.75

41. David Dinges PhD Wei-Ting Hwang PhD Linda Scott PhD, RN David Dinges PhD Wei-Ting Hwang PhD Linda Scott PhD, RN Acknowledgements American Association of Critical Care Nurses American Nurses Association Agency for Healthcare Research and Quality (R01 HS11963) American Nurses Foundation Grant (Scott) American Association of Critical Care Nurses American Nurses Association Agency for Healthcare Research and Quality (R01 HS11963) American Nurses Foundation Grant (Scott)