According to Gaba, who directs VA's Patient Safety Center of Inquiry in Palo Alto, fatigue among health care workers probably presents a danger well outside the bounds of what is accepted from any other high-hazard occupation.
The authors included working shorter shifts, and limiting high-intensity work to normal daylight hours among the changes they suggest in their policy analysis. Such changes might promote harmony with the body's natural sleep cycle, and improve patient safety.
"We need to come to grips with this issue, not only for clinicians in training, but for experienced doctors and nurses as well," said Gaba. "Dealing with it is a very complicated business, but we can't just pretend that it's not an issue."
Airline pilots and truck drivers work under strict guidelines to prevent fatigue-related errors, but no comparable comprehensive regulations exist for medical professionals. Although there is no clinical proof that tired doctors and nurses are dangerous for patients, Gaba and Howard say the risk is obvious.
"It defies logic to think that fatigue–related impairment doesn't play a significant role in performance and safety issues in the medical field, when so many other industries acknowledge the inherent risks," said Gaba. "We believe, for the same reasons that society regulates and limits fatigue impairment in the interest of safety, that it is a safety issue in health care, too. That goes for the safety of clinicians themselves as well as for patient safety."
Among health care professionals, residents in training may be the most notoriously overworked -- enduring workweeks that sometimes last 120 hours. Gaba said problems could arise because individuals ignore or deny their fatigue, and work tired for long periods. He compared being awake for 24 hours to having a blood alcohol level of .10 percent – too impaired to drive.
"It is rare for something bad to happen when a doctor falls asleep for a few seconds or a few minutes, although there are case reports of just that occurring," Gaba said. "But just as it is unacceptable to muddle through medical work while impaired by alcohol, it should be equally unacceptable to work while impaired by fatigue."
Besides limiting work hours, Gaba said medical professionals must change the way they think about fighting fatigue and resting on the job by making it part of their daily plan. "Clinicians could easily make more strategic use of caffeine and take brief naps during their most vulnerable periods -- say between the hours of 2 and 4 a.m. This is when the body's natural sleep cycle can develop an overwhelming demand for rest," he said.
Scheduling elective surgery and other high-intensity activities during daylight hours when people are more alert, is another means of reducing hazards on long shifts. However, bringing more work (and more workers) to daytime hours is an expensive option. And according to Gaba, since residents represent cheap labor, nearly all options for reducing their work hours are expensive.
Very few cost analysis studies of reduced resident work hours were available to Gaba and Howard. One study, published in 1994, noted expense between $1.4 and $1.8 billion per year nationwide. "There's no way you can respond to the issue of fatigued clinicians without causing major changes in the organizational structure of the way work gets done," Gaba said. "And some of these changes are going to cost a lot of money."
Gaba also stated that despite the lack of a "smoking gun" study proving that fatigue causes errors that harm patients, absolute proof is hardly needed to act. "It is obvious that residents and other medical professionals are regularly working far beyond the limits that society deems acceptable," he said. "If the medical profession does not implement meaningful changes for trainees and eventually for experienced clinicians, they may be ultimately forced upon us."
This work was funded in part by the Patient Safety Centers of Inquiry program of the Veterans Health Administration.
Journal
New England Journal of Medicine