Infants at Risk: When Nurse Fatigue Jeopardizes Quality Care

Advances in Neonatal Care

Volumn 6, Issue 3, 2006, Pages 120-126

  Dean, Grace E ^a   Scott, Linda D ^b   Rogers, Ann E ^a  

^a UNIVERSITY OF PENNSYLVANIA   (United States)

^b GRAND VALLEY STATE UNIVERSITY   (United States)

Author keywords

fatigue; medical error; newborn intensive care; nurses; safety; sleep deprivation

Indexed keywords

ARTICLE; FATIGUE; HEALTH CARE QUALITY; HUMAN; MEDICAL ERROR; NEWBORN; NEWBORN NURSING; NURSING STAFF; PERSONNEL MANAGEMENT; STANDARD; UNITED STATES; WORK SCHEDULE;

FATIGUE; HUMANS; INFANT, NEWBORN; MEDICAL ERRORS; NEONATAL NURSING; NURSING STAFF, HOSPITAL; PERSONNEL STAFFING AND SCHEDULING; QUALITY ASSURANCE, HEALTH CARE; UNITED STATES; WORK SCHEDULE TOLERANCE;

EID: 33646901871     PISSN: 15360903     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.adnc.2006.02.001     Document Type: Article

References (69)

1. March of Dimes. Babies Born Too Soon and Too Small (2005). http://www.marchofdimes.com/peristats/pdflib/195/99.pdf November, Available at: www.marchofdimes.com/peristats/pdflib/195/99.pdf. Accessed December 12, 2005
2. Clark R., Powers R., White R., Bloom B., Sanchez P., et al. Nosocomial infection in the NICU. a medical complication or unavoidable problem?. J Perinatol 24 (2004) 382-388
3. Modi N. Management of fluid balance in the very immature neonate. Arch Dis Child Fetal Neonatal Ed 89 (2004) F108-F111
4. Kaushal R., Bates D.W., Landrigan C., McKenna K.J., Clapp M.D., et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 285 (2001) 2114-2120
5. Frey B., Kehrer B., Losa M., Braun H., Berweger L., et al. Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit. experience with the system approach. Intensive Care Med 26 (2000) 69-74
6. Leape L.L., Bates D.W., Cullen D.J., Cooper J., Demanaco H.J., et al. Systems analysis of adverse drug events. JAMA 274 (1995) 35-43
7. Ebright P.R., Patterson E.S., Chalko B.A., and Render M.L. Understanding the complexity of registered nurse work in acute care settings. J Nurs Admin 33 (2003) 630-638
8. Reason J. Human error. models and management. Br Med J 320 (2000) 768-770
9. Hughes R., and Stone P. The perils of shift work: evening shift, night shift, and rotating shifts: are they for you?. Am J Nurs 104 (2004) 60-63
10. Folkard S., and Akerstedt T. A three process model of the regulation of alertness-sleepiness. In: Broughton R., and Ogilvie R. (Eds). Sleep, Arousal and Performance. Problems and Promises (1991), Birkhauser, Boston, Mass 11-26
11. Fletcher A., and Dawson D. A quantitative model of work-related fatigue; empirical evaluations. Ergonomics 44 (2001) 475-488
12. National Sleep Foundation. 2005 Sleep in America Poll (2005). http://www.sleepfoundation.org/_content/hottopics/2005_summary_of_findings.pdf Washington DC; March 29. Available at: www.sleepfoundation.org/_content/hottopics/2005_summary_of_findings.pdf. Accessed December 12, 2005
13. National Sleep Foundation. 2003 Sleep in America Poll (2003). http://www.sleepfoundation.org/_content/hottopics/2003SleepPollExecSumm.pdf Washington DC; March 10. Available at: www.sleepfoundation.org/_content/hottopics/2003SleepPollExecSumm.pdf. Accessed December 12, 2005
14. Van Dongen H.P.A., Maislin G., Mullington J.M., and Dinges D.F. The cumulative cost of additional wakefulness. dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 26 (2003) 117-126
15. Harrison Y., and Horne J.A. The impact of sleep deprivation on decision making. a review. J Exp Psychol Appl 6 (2000) 236-249
16. Dinges D.F., Pack F., Williams K., Gillen K.A., Powell J.W., et al. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 20 (1997) 267-277
17. Howard S.K., Gaba D.M., Smith B.E., Weinger M.B., Herndon C., et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology 98 (2003) 1345-1355
18. Gaba D.M., and Howard S.K. Patient safety. fatigue among clinicians and the safety of patients. N Engl J Med 347 (2002) 1249-1255
19. Lockley S.W., Cronin J.W., Evans E.E., Cade B.E., Lee C.J., et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 351 (2004) 1829-1837
20. Landrigan C.P., Rothschild J.M., Cronin J.W., Kaushal R., Burdick E., et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 351 (2004) 1838-1848
21. Baldwin Jr. D.C., and Daugherty S.R. Sleep deprivation and fatigue in residency training. results of a national survey of first-and second-year residents. Sleep 27 (2004) 217-223
22. Lee K.A. Self-reported sleep disturbances in employed women. Sleep 15 (1992) 493-498
23. Clissold G., Smith P., Accutt B., and DiMilia L. A study of female nurses combining partner and parent roles with working a continuous three-shift roster. the impact on sleep, fatigue and stress. Contemp Nurse 12 (2002) 294-302
24. Totterdell P., Spelten E., Barton J., Smith S., and Folkard S. On-shift and daily variations in self-report and performance measures in rotating and permanent night shift nurses. Work Stress 9 (1995) 187-197
25. Totterdell P., Spelten E., Smith L., Barton J., and Folkard S. Recovery from work shifts. how long does it take?. J Appl Psychol 80 (1995) 43-57
26. Rogers A.E., Hwang W.-T., Scott L.D., Aiken L.H., and Dinges D.F. Hospital staff nurse work hours and patient safety. Health Affair 23 (2004) 202-212
27. Caldwell J.A. The impact of fatigue in air medical and other types of operations. a review of fatigue facts and potential countermeasures. Air Med J 20 (2001) 25-32
28. Rosekind M.R., Gander P.H., Gregory K.B., Smith R.M., Miller D.L., et al. Managing fatigue in operational settings 1. physiological considerations and countermeasures. Behav Med 21 (1996) 157-165
29. Braver E.R., Preusser C.W., Preusser D.F., Baum H.M., Beilock R., et al. Long hours and fatigue. a survey of tractor-trailer drivers. J Public Health Pol 13 (1992) 341-366
30. Tzamalouka G., Papadakaki M., and El Chliaoutakis J. Freight transport and non-driving work duties as predictors of falling asleep at the wheel in urban areas of Crete. J Safety Res 36 (2005) 75-84
31. Belenky G., Wesensten N.J., Thorne D.R., Thomas M.L., Sing H.C., et al. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery. a sleep dose-response study. J Sleep Res 12 (2003) 1-12
32. Caldwell J.A., and Caldwell J.L. Fatigue in military aviation. an overview of US military-approved pharmacological countermeasures. Aviat Space Environ Med 76 suppl (2005) C39-C51
33. Gold D.R., Rogocz S., Bock N., Tosteson T.D., Baum M., et al. Rotating shift-work, sleep and accidents related to sleepiness in hospital nurses. Am J Public Health 7 (1992) 1011-1014
34. Smith L., Folkard S., and Poole C.J.M. Increased injuries on the night shift. Lancet 344 (1994) 1137-1139
35. Rosa R.R. Examining work schedules for fatigue. it's not just hours of work. In: Hancock P.A., and Desmond P.A. (Eds). Stress, Workload, and Fatigue (2001), Lawrence Erlbaum Associates, Mahwah, NJ 513-528
36. Folkard S. Effects on performance efficiency. In: Colquhoun W.P., Costa G., Folkard S., and Knauth P. (Eds). Shiftwork. Problems and Solutions (1996), Peter Lang Publishing Inc, Frankfort am Main, Germany 65-87
37. Monk T.H. Shiftworker performance. In: Scott A. (Ed). Occupational Medicine State of the Art Reviews, Vol. 5. Shiftwork (1990), Hanley and Belfus, Inc, Philadelphia, Pa 183-198
38. Monk T.H., Folkard S., and Wedderburn A.I. Maintaining safety and high performance on shiftwork. Appl Ergon 27 (1996) 17-23
39. Luna T.D., French J., and Mitcha J.L. A study of USAF air traffic controller shiftwork. sleep, fatigue, activity, and mood analyses. Aviat Space Environ Med 68 (1997) 18-23
40. Wylie C., Schultz T., Miller J., Mitler M., and Mackie R. Commercial Motor Vehicle Driver Fatigue and Alertness Study (1996), Prepared for the Federal Highway Commission, Trucking Research Institute, American Trucking Association Foundation, and the Transportation Development Centre, Safety and Security, Transport Canada, Montreal, Canada. http://www.fmcsa.dot.gov/facts-research/research-technology/publications/cmvfatiguestudy.htm FHWA Report number: FHWA-MC-97-001, TC Report number TP12876E. Available at: www.fmcsa.dot.gov/facts-research/research-technology/publications/cmvfatiguestudy.htm. Accessed December 12, 2005
41. Lavie P., Chillag N., Epstein R., Tzischinsky O., Givon R., et al. Sleep disturbance in shift workers. a marker for maladaptation syndrome. Work Stress 3 (1989) 33-40
42. Walsh J.K., Tepas D.I., and Moss P.D. The EEG sleep of night and rotating shift workers. In: Johnson L.C., Tepas D.I., Colquhon W.P., and Colligan M.J. (Eds). Biological Rhythms, Sleep, and Shift Work (1981), Spectrum, New York, NY 371-381
43. Van Dongen H.P.A., Rogers N.L., and Dinges D.F. Sleep debt. theoretical and empirical issues. Sleep Biol Rhythm 1 (2003) 4-12
44. Dinges D.F., Graeber R.C., Rosekind M.R., Samel A., and Wegmann H.M. NASA Technical Memorandum 110404, Principles and Guidelines for Duty and Rest Scheduling in Commercial Aviation (1996), National Aeronautics and Space Administration, Ames Research Center, Moffett Field, CA. http://human-factors.arc.nasa.gov/zteam/fcp/pubs/p.and.g.intro.html Available at: human-factors.arc.nasa.gov/zteam/fcp/pubs/p.and.g.intro.html. Accessed December 12, 2005
45. Howard S.K., Gaba D.M., and Rosekind M.R. Evaluation of daytime sleepiness in resident anesthesiologists. Anesthesiology 83 (1995) A1007
46. Howard S.K., Gaba D.M., and Rosekind M.R. Subjective assessment of sleepiness and sleep onset perceptions of resident anesthesiologists. Anesthesiology 83 (1995) A1009
47. Dorrian J., Lanond N., and Dawson D. The ability to self-monitor when fatigued. J Sleep Res 9 (2000) 137-144
48. Scott L.D., Rogers A.E., Hwang W.-T., and Zhang Y. The effects of critical care nurse work hours on vigilance and patients' safety. Am J Crit Care 15 (2006) 30-37
49. Dawson D., and McCulloch K. Managing fatigue. it's about sleep. Sleep Med Rev 9 (2005) 365-380
50. Dawson D., and Reid K. Fatigue, alcohol, and performance impairment. Nature 388 (1997) 235
51. Reid K., and Dawson D. Comparing performance on simulated 12 hour shift rotation in young and older subjects. Occup Environ Med 58 (2001) 58-62
52. Gillespie A., and Curzio J. A comparison of a 12-hour and eight-hour shift system. Nurs Times 92 (1996) 36-39
53. Josten E.J., Ng A.T.J.E., and Thierry H. The effects of extended workdays on fatigue, health, performance and satisfaction in nursing. J Adv Nurs 44 (2003) 643-652
54. Stenuit P., and Kerkhofs M. Age modulates the effects of sleep restriction in women. Sleep 28 (2005) 1283-1288
55. Kuh D.L., Hardy R., and Wadsworth M. Women's health in midlife. the influence of the menopause, social factors and health in earlier life. Br J Obstet Gynaecol 104 (1997) 1419
56. Owens J.F., and Mathews K.A. Sleep disturbance in healthy middle-aged women. Maturitas 30 (1998) 41-50
57. Rosekind M.R., Co E.L., Gregory K.B., and Miller D.L. Crew Factors in Flight Operations XIII. A Survey of Fatigue Factors in Corporate/Executive Aviation Operations (2000), NASA Ames Research Center, Moffitt Field, Calif Technical Memorandum No. 108839
58. Galinsky T., Swanson N., Sauter S., Hurrell J.J., and Schleifer L.M. A field study of supplementary rest breaks for data entry operators. Ergonomics 43 (2000) 622-638
59. Tucker P. The impact of rest breaks on accident risk, fatigue and performance. a review. Work Stress 17 (2003) 123-127
60. Tucker P., Folkard S., and Macdonald I. Rest breaks and accident risk. Lancet 361 (2003) 680
61. Lilley R., Feyer A.M., Kirk P., and Gander P. A survey of forest workers in New Zealand. do hours of work, rest, and recovery play a role in accidents and injury?. J Safety Res 33 (2002) 53-71
62. Krueger G.P. Fatigue, performance, and medical error. In: Bogner M.S. (Ed). Human Error in Medicine (1994), Lawrence Erlbaum Associates, Hinsdale, NJ 311-326
63. Rosekind M.R., Smith R.M., Miller D.L., Co E.L., Gregory K.B., et al. Alertness management. strategic naps in operational settings. J Sleep Res 4 S2 (1995) 62-66
64. Rosekind M.R., Gander P.H., Connell L.J., and Co E.L. Crew factors in flight operations X. Alertness management in flight operations (1999), United States Department of Transportation. http://www.human-factors.arc.nasa.gov/ihs/publications_details.php?id=75 Available at: www.human-factors.arc.nasa.gov/ihs/publications_details.php?id=75. Accessed December 12, 2005
65. Buus-Frank M.E. Practicing under the influence of fatigue (PUIF). a wake-up call for patients and providers. Adv Neonatal Care 5 (2005) 55-61
66. Leape L.L., Bates D.W., Cullen D.J., Cooper J., Demonaco H.J., et al., ADE Prevention Study Group. Systems analysis of adverse drug events. JAMA 274 (1995) 35-43
67. Webb W. Partial and differential sleep deprivation. In: Kales A. (Ed). Sleep. Physiology and Pathology-A Symposium (1969), JB Lippincott, Philadelphia, Pa 221-231
68. Rogers A.E., Hwang W.T., and Scott L.D. The effects of work breaks on staff nurse performance. J Nurs Adm 34 (2004) 512-519
69. Hughes R.G. First, do no harm. Avoiding the near misses. Am J Nurs 104 (2004) 81 83-84