Fatigue in Hospitals: A Rx for Danger

by Suzanne Gordon

IS ANYONE awake in America’s teaching hospitals? Just barely, according to several new studies.

In spite of limits on hospital residency program hours, interns are still too exhausted to protect either their patients or themselves. In addition, nurses — who used to be alert enough to catch the errors of an inexperienced or exhausted resident — are now working too long and making more errors themselves.

The most recent evidence of this problem appeared in the latest issue of the Journal of the American Medical Association. Researchers at the Harvard Work Hours, Health and Safety Group assessed the efficacy of standards limiting resident hours that the Accreditation Council for Graduate Medical Education implemented in 2003.

Rather than working 100 hours or more a week, interns are supposed to work no more than 80 hours a week, averaged over a four-week period. The Accreditation Council also limits the number of consecutive hours an intern can work — no more than 30 — a marathon shift that can and is repeated as often as every third day. If the council receives complaints from residents that these limits are being violated, the only penalty is that the programs could lose accreditation.

To find out how these standards are working, the Harvard researchers surveyed 4,015 of the 37,253 interns in US residency programs. They found that 84 percent of interns reported work hours in violation of the standards one or more months. Other researchers at Harvard studied whether interns who work long hours get more needlestick and scalpel injuries. And researchers from the Mayo Clinic considered whether residents experience burnout and emotional problems when they discover that they make medical errors.

When compared with other workers whose fatigue poses a risk to the public — such as long haul truck drivers or commercial airline pilots whose work hours are tightly controlled — working 30 consecutive hours hardly seems an advance. And indeed, because of fatigue and lack of concentration, many interns are making preventable medical errors, driving while drowsy (with a subsequent higher rate of car crashes) and sticking themselves with needles or cutting themselves with scalpels.

This new finding puts more interns at risk for potentially fatal blood borne illnesses such as hepatitis or HIV/AIDS. When exhausted interns stick or cut themselves, they then become the patient — one who has been prescribed a course of preventive medicine that is as toxic as it is expensive. To add insult to injury, if they make medication errors, they are at risk for burnout, depression, and a reduced ability to empathize with patients and one another.

In spite of all this, interns are afraid to complain about overwork because they fear their careers will suffer if the Accreditation Council shuts down their program. This combustible combination of overwork, injury, depression, and loss of empathy becomes even more worrisome when we consider changes in nurses’ working conditions.

Hospital nurses today aren’t only taking care of more patients, they are also working longer hours. Ann E. Rogers, a sleep researcher at the University of Pennsylvania School of Nursing, and Alison Trinkoff of the University of Maryland School of Nursing have documented that the eight-hour shift has largely become a historical artifact. Twelve-plus hour shifts — sometimes four or five in a row — are now norm. With no regulation of how long nurses can work or how many consecutive long shifts they can put in, nurses are making more errors themselves.

Many may be too tired to catch an error made by exhausted interns and residents. “Nurses are critical in preventing an error from reaching a patient,” says Simon Ahtaridis , national president of the Committee of Interns and Residents and chief resident at Cambridge Hospital. If nurses are also exhausted, he explains, they may not detect a different dose of a medicine, or overlook an important patient complaint.

Until there is the public accountability that federal regulation provides, patients — as well as doctors and nurses — will continue to pay with their health and even their lives.

Suzanne Gordon is author of “Nursing Against the Odds: How Healthcare Cost-Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care.” She can be reached via her website: www.SuzanneGordon.com. This article was originally published in the Sept. 22, 2006 Boston Globe. Republished with the author’s permission.