9 Ways to Prevent Adverse Events
The Joint Commission advises all organizations perform nine tasks to avoid fatigue-related adverse events:
1. Assess your organization for fatigue-related risks, including off-shift hours and consecutive shift work, and review staffing and other policies to address extended work shifts and hours.
2. Assess patient hand-off processes and procedures since these transitions are a time of high-risk for errors related to fatigued staff.
3. Invite staff input into designing work schedules to minimize fatigue.
4. Create a fatigue management plan with scientific strategies for fighting fatigue, such as engaging in conversations with others (not just listening and nodding), doing something that involves physical action such a stretching, consuming caffeine but not at times when one is already alert, and taking short naps of about 45 minutes.
5.Educate staff about sleep hygiene, which includes getting enough sleep and taking naps, engaging in pre-sleep routines such as yoga or reading, and avoiding food, alcohol or stimulants such as caffeine that can impact sleep.
6. Provide opportunities for staff to express concerns about fatigue.
7. Encourage teamwork to support members of the staff who work extended work shifts or hours, such as using a system of independent second checks for critical tasks or complex patients.
8. Consider fatigue as a potentially contributing factor when reviewing all adverse events.
9. Assess the organization's ability to provide sleep breaks to ensure it fully protects sleep to ensure good quality sleep, including providing uninterrupted coverage, response to pagers and phones and coverage of admissions and continuing care, and provide a cool, dark, quiet, comfortable room with eye masks and ear plugs if necessary.