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Fighting fatigue, errors in nursing profession by Laurie Zone-Smith, R.N. Clinical Services Administration It’s no secret that a nationwide nursing shortage stresses one of the most trusted and ethical health professions. The nature of that stress ranges from increased working hours to decreased numbers of nurses working on hospital floors, intensive care units and clinics. A recent study led by nurse researchers at the University of Pennsylvania tracked 393 hospital nurses and found about 40 percent of their shifts exceeded 12.5 hours during a four-week period.  These extended shifts raised the risk of medical mistakes, such as dispensing the wrong medication or the wrong dosage, up to three times the normal rate. The nurses from the University of Pennsylvania study worked an average of 55 minutes longer than scheduled each day, with one third of the nurses working overtime every day they worked during the four-week study. Causes for the increase may seem obvious, more overtime equals more physical and emotional exhaustion, less attention to detail and overall burnout. The MUSC Medical Center, aware of the problems faced by nursing staff on a daily basis, has several safeguards in place to combat the chances for increased medical errors. MUHA staff nurses and leadership employ a variety of research findings, best practices and technologies to evaluate processes and standardize and monitor progress to assure that the highest quality patient care is delivered every day.  “Research conducted on fatigue in nursing is lacking compared to medicine and industries such as aeronautics. Findings that affect patient and staff safety should be the trigger for nurses to change their work environments,” said MUSC’s chief nurse executive Marilyn Schaffner, R.N. “Mandatory overtime is not legislated in South Carolina as it is in other states. Interestingly, this study notes that nurses who wanted to work a 12.5 hour or longer shift reported fewer errors than those working extended overtime shifts. Perhaps nurses are planning their rest and sleep prior to chosen shifts.  Our monthly average of core nursing staff overtime accounts for only 4 percent of budgeted nurses.”  The 2004 Institute of Medicine (IOM) report, “Keeping Patients Safe—Transforming the Work Environment of Nurses,” advised that the strengthening of patient safety in hospitals, the need for attention to safety defenses, and reinforcing changes in the nursing work environment must involve leadership, the workforce, work processes and organizational culture changes. MUSC efforts to assure a safe hospital environment follow numerous IOM recommendations.  For example: A Culture of Excellence: MUSC is in pursuit of the ANCC (American Nurses Credentialing Center) Magnet Recognition Award which identifies hospitals that have met the highest standards for excellence in nursing care. Nurse sensitive indicators and benchmarks are tracked to evaluate organizational and unit specific safety records including: staffing skill mix, nursing care hours provided, pressure ulcers, patient injury falls and nursing staff satisfaction. Bedside nurses are given permission to be the drivers in nurse decision making, take control over their practice environment to identify vulnerability, and make changes to decrease errors and increase patient and employee safety. Blame-Free Safety Culture: In January 2003, a new error reporting system Patient Safety Net (PSN) was deployed to every nursing location for easy access. All professional staff are strongly encouraged to report areas of concern so any unwanted events or ineffective system processes can be detected, corrected and monitored regularly at all levels of the organization.  Automation: “Automation will play a major role in reducing medication errors in the future,” said Carol Younker, MUHA risk manager. Technologies that alert clinicians to possible drug contradictions such as bar coding, computerized nursing documentation, and physician order entry systems are currently being evaluated or are being implemented and can help nurses avoid errors and prompt changes in clinical decisions.  Adequacy of nursing staff: Nurses determine staffing guidelines and adjustments based on regulatory or professional association recommendations, unique unit trends such as patient activity, service quality and safety trends on the unit, nurse experience and expertise. Nurses can compare scheduled staff hours to the assigned nurse’s predicted intensity time required to provide care to a patient.  Staff nurse fatigue is a component considered in MUHA’s evidence based nurse staffing model.  Monitoring the data: Clinical information systems enable staff nurses to provide vital information to multiple databases and comprehensive reports are available to leadership for analysis. Databases developed by MUHA nurses and interdisciplinary team members include: the Core Nurse Staffing Reports, Medication Administration Record Discrepancy Database, Medication Administration High Alert Drug Database, Nursing Documentation Audits and Nursing Intensity Database. Pharmacists and nurses perform daily medication administration reviews and stimulate communication and collaboration with patient care partners. The questions asked when reviewing this data are, “Is this the standard of excellence we expect? Can it be improved?” In a perfect world, nurses would work fewer long shifts and less overtime. But a challenge lies in limiting the time that individual nurses work at the hospital, especially when most overtime and long shifts are not planned in advance.    Friday, July 16, 2004 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.