Tag Archives: fatigue

Root Cause

Disabled resident dies when caregiver falls asleep

By ThinkReliability Staff

A physically disabled resident in a New York state-run care home required checks every two hours to ensure he was receiving adequate oxygen.  On the night of September 10, 2013, his nurse fell asleep, and he went more than 8 hours without the checks.  During this time, his oxygen level dropped to 40% (anything below 90% is considered dangerous), and he later died of hypoxic brain injury.

Says Patricia Gunning, prosecutor for the New York State (NYS) Justice Center for the Protection of People with Special Needs, “This case serves as a tragic reminder of the serious risk posed by an all too common workforce problem of caregiver fatigue or workers sleeping on shifts.”

Sadly, “all too common” turned out to be all too true.  The NYS Justice Center for the Protection of People with Special Needs was formed in mid-2013, and oversees agencies responsible for more than a million people in state care or state-funded nonprofits.  During its first year, it found 458 reports alleging abuse or neglect that cited a caregiver sleeping on the job.  This included caregivers who slept through a resident’s grand-mal seizure and a resident’s elopement, residents with unattended access to medications and food, and residents who were in a car driven by a caregiver who fell asleep at the wheel.

Even with a seemingly overwhelming problem such as this, progress can be made by looking at the specifics of one case, identifying causes that led to the problem, and developing solutions.  These solutions can then be considered for individual or widespread application.  We will examine the specifics of this case in a Cause Map, or visual root cause analysis, which lays out the cause-and-effect relationships leading to a problem.

The problem being examined is determined by the impact to an organization’s goals.  In this case, the resident safety goal was impacted because of the death of the resident.  The resident services goal was impacted because the resident did not receive adequate oxygen.  The compliance goal is impacted because of the felony charges against the nurse, who was sentenced to 90 days in prison.

Beginning with the most prominent impacted goal – in this case the resident safety goal – and asking “why” questions develop the cause-and-effect relationships that led to that impact.  In this case, the resident died from hypoxic brain injury (per diagnosis), from a lack of oxygen.  Due to the resident’s physical disability, his oxygen delivery equipment was required to be checked every 2 hours around the clock.  On the night of September 10 to September 11, more than 8 hours passed between checks, at which point the patient was found unresponsive.  (He died two weeks later.)

The resident’s oxygen delivery was not checked for more than 8 hours (as opposed to the required two) because the caregiver on duty had fallen asleep.  Testimony from the nurse in question as well as others from the facility describing sleeping on overnight shifts as a common occurrence.  Later research from the NYS Justice Center for the Protection of People with Special Needs found that many incidents involving caregiver sleeping on duty involved staff working extended or otherwise non-traditional work shifts.  The nurse who fell asleep on duty worked 12-hour night shifts at a site where many signed up for overtime and just barely passed duty hour requirements.

In response to the numerous caregiver sleeping events it discovered, the NYS Justice Center for the Protection of People with Special Needs has provided a toolkit aimed to protect people with special needs from caregiver fatigue.  The Center recommends that care provider agencies implement & regularly review policies meant to deter and detect sleeping on the job, establish contingency plans to relieve staff found unfit for duty, and provide assistance to residents in calling for help if caregiver is unresponsive.  Due to the myriad issues associated with caregiver fatigue, the American Nurses Association (ANA) continues to fight to reduce nurse fatigue, and possible harm to patients.

To see a one-page PDF with an overview of the investigation related to the resident lack of oxygen due to caregiver sleeping, click on “Download PDF” above.  Or, click here to learn more.

Root Cause

Are Medical Residents Dangerously Fatigued?

By Kim Smiley

Medical residents work extremely long, tiring schedules on their arduous path to becoming physicians.  Possible consequences of this demanding schedule have long been debated.  Many wonder if it’s safe to have someone who has been on duty for 24 hours straight treating patients.

This issue can be explored by building a Cause Map, or visual root cause analysis.  A Cause Map is built by asking “why” questions and laying out the different causes that contributed to an issue to the cause-and-effect relationships.  In this example, there is potential risk to patients and to the medical residents themselves.  Patients may be at risk because fatigued medical residents are treating patients and fatigued people are more likely to make mistakes, increasing the chance of a medical error that affects patient safety.  Residents are fatigued because they work long hours and the current regulations allow 80 hour work weeks.

Additionally, the health of the residents themselves may be at risk.  A poll by the Mayo clinic found that 11 percent of medical residents had been in an auto accident.  The poll also found that 8 percent of residents reported having at least one blood or body fluid exposure due to fatigue or stress, potentially exposing them to any number of diseases.  Sleep deprivation itself can also have long term health consequences increasing the likelihood of a number of illness including heart disease and gastrointestinal problems.

While there is ongoing debate on whether residents are still working too many hours, there have been changes made to reduce resident fatigue. In 2003, residents were limited to 80 hours per week by the Accreditation Council for Graduate Medical Education.  Prior to this move, there was essentially no limit to the hours a resident could log.  This issue isn’t black and white and there are also many who argue that the limits have had negative unintended consequences.  Fewer hours in the hospital mean that residents see fewer patients and have less experience when they become independent physicians.  Limiting shifts also increases the potential for each patient to be seen by more doctors and for essential information to be lost during turnovers.  This isn’t an issue with a clear answer and any additional restrictions in the hours a resident is allowed to work will need to be mitigated with effective methods of turning over patient care and assurances that residents are getting adequate training.

This is a good example to demonstrate the important of taking an investigation past determining that the problem is caused by “human error”.  Medical errors are caused by human errors, but the most useful part of the investigation usually comes from asking why the error was made.  Was the person overly fatigued?  Was the procedure confusing?  Would the process go smoother with a phase to verify information or a checklist?  An investigation shouldn’t be stopped at “human error”; it should be taken a few steps farther to see what may have contributed to the error and what changes may help prevent a similar error in the future.