The Joint Commission – Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety

Abstract

The link between health care worker fatigue and adverse events is well documented, with a substantial number of studies indicating that the practice of extended work hours contributes to high levels of worker fatigue and reduced productivity. These studies and others show that fatigue increases the risk of adverse events, compromises patient safety, and increases risk to personal safety and well-being. While it is acknowledged that many factors contribute to fatigue, including but not limited to insufficient staffing and excessive workloads, the purpose of this Sentinel Event Alert is to address the effects and risks of an extended work day and of cumulative days of extended work hours.