Can Care Provider Fatigue Contribute to Malpractice?

With the possible exception of airline pilots, air traffic controllers, parents of newborns and owls, registered nurses working night shifts, and advanced practice providers (nurse-midwives) with demanding on-call responsibilities, many tend to experience unprecedented levels of sleep deprivation from their career choices. If not adequately addressed, providers working long stretches of on-duty time can pose safety risks to the patients they care for. Long hours performing life-supporting patient care may leave registered nurses (RNs), advanced practice registered nurses (APRNs), and certified nurse-midwives (CNMs) vulnerable to the effects of sleep deprivation, most notably exhaustion and fatigue.

Workers in any profession can experience fatigue. However, in the healing professions, the difference lies in the potential for human harm and death. Studies have shown that sleep deprivation and disruption of an individual’s circadian rhythm interfere with the quality of patient care due to prolonged hours of work. Similar to the nursing industry, the airline industry prioritizes the safety and well-being of its clients and employees. But unlike nursing, airlines have established strict protocols limiting the number of consecutive hours an employee can work within a given time frame. This industry has recognized the connection between rest and safety, and the necessity of protecting the public from employee error caused by insufficient restorative sleep.

Healing Professions Most At Risk

Unfortunately, the RN/APRN/CNM professions are unable to enjoy these protections. A recurring theme in nursing education is the promise of quality care in every patient encounter. As a result of their educational experience, registered nurses and nurse-practitioners are expected to maintain the highest levels of care for their patients 1. To “do no harm” is an ethical principle that guides clinical practice for all nurses and healthcare professionals. Alarmingly, medical errors are ranked, in the company of heart disease and cancer, as the 3rd leading cause of patient death in the United States, with medication administration errors occurring most frequently. Currently, hospital medication errors are estimated to cause at least one death every day and injure 1.3 million patients every year.

To perform their roles effectively, providers must be well-rested and alert; a challenging requirement as a result of clinician shortages, which have increased since the advent of the novel coronavirus in 2019 (COVID-19). In 2022, the professional nursing vacancy rate in the U.S. was 17%, a 7.1% increase from 2021. To maintain 24/7 nursing coverage, experts contend that nurse staffing for most hospitals will continue to rely on extended work hours, including 12+ hour shifts, rotating shifts, and mandatory overtime. 2 Poor sleep quality from overwork ranks among the most common causes of nurses’ fatigue, decreased alertness, and sick calls. Working in a mentally and physically demanding profession and a complex work environment has also contributed to nurses experiencing extreme fatigue and decreased alertness. Various studies have linked nursing fatigue to a wide range of adverse outcomes, such as drowsy driving, decision regret, medication administration errors, and needle-stick injuries. 3 Midwife fatigue can provoke more serious outcomes.

Case Study

On July 4, 2006, a veteran obstetrical nurse worked two 8-hour shifts in 24 hours. She did not go home between her shifts and slept on a cot during the night. She was close to the end of her second shift, on July 5th, when she unknowingly administered the wrong medication, resulting in her patient’s death. Following this tragedy, the nurse was charged with “criminal neglect of a patient causing great bodily harm”, a statutory felony. She was convicted, served 3 years on probation, and was prevented from ever working in a critical care setting, such as labor and delivery. This was the first time a nurse in her State had ever been criminally charged for a medication error.4 The human component of medical errors is absolutely related to fatigue and decreased alertness, which causes “degradation in performance”, “impaired reaction time”, and a “lapse of attention affecting successful completion of required tasks”.5

What’s At Stake?

So what is actually at stake when a nurse or midwife on duty is fatigued? The rate of medication errors has been shown to increase after 12 continuous hours of work or greater than 60 hours per week. After 24 hours of sleep deprivation and interruption, the detrimental effects on decision-making and mental competence are equivalent to the impact of a blood alcohol concentration of 0.10%. This ETOH level exceeds many States’ limits for determining severe impairment.

The National Transportation Safety Board advises a blood alcohol concentration of no greater than 0.05% blood alcohol concentration to support the prevention of traffic fatalities. Nursing fatigue costs the United States billions of dollars every year.6 Patient safety is a global healthcare concern (The Health Foundation, 2013; World Health Organization [WHO], 2004). Again, the most frequently reported causes of patient morbidity and mortality in hospitals are medication administration errors (Adams and Koch, 2010). Working rotating shifts is a typical requirement of an RN’s/APRN’s employment. These schedules can disrupt an individual’s internal circadian clock, affecting sleep-wake patterns and making it difficult to obtain sufficient, restful sleep. One study found that medication errors increased when nurses worked irregular shifts with additional, unplanned overtime (Saleh et al., 2014). Of the 38 studies included in this review, 31 found that fatigue contributed to medication errors and near misses. 7

Nursing Fatigue Among the Highest Contributors To Patient Death

There is little doubt, both empirically and practically, that nursing fatigue is a significant contributor to patient injury and death. What appears to be missing is any serious commitment on the part of corporate healthcare to explore solutions to the problem. Unfortunately, the literature suggests that nurses should be personally responsible for the number of their working hours, monitoring their own fatigue levels to prevent serious medical errors.

Transferring 100% of the responsibility to nurses without additional facility safeguards is not enough. For example, how would members of the public feel about boarding an airplane if there were no effective safety protocols ensuring a pilot’s alertness? And what about the airline professionals sitting at screens, ensuring that hundreds of planes in flight (and on the ground) do not violently collide? Bottom line: We want professionals who protect public safety to be rested! Unfortunately, hospital corporations appear reluctant to accept responsibility.

Patients and nurses are vulnerable to the negative consequences of overburdened, exhausting staff schedules. Healthcare entities must be encouraged to address the causes of staff fatigue and establish protections for patients and nursing staff alike. Dangerous staffing environments that may harm patients must be mitigated. Furthermore, hospital care disasters such as these are guaranteed to invite claims of nursing negligence and corporate malpractice. It is rare for criminal charges to be filed unless there is evidence of intentional, rather than negligent, harm.

Personal Injury Attorneys Aware

Most personal injury attorneys recognize that the hospital can also be sued in these scenarios, separate from individual nurses or APRNs. Suing a hospital will require scrutiny of its staffing and hiring policies, which may lead to additional claims of corporate negligence.

“Errors are made by highly competent, careful, and conscientious people for the simple reason that everyone makes mistakes every day. Thus, what we need to think about is not who is at fault or who is to blame, but why and how errors occur and, more importantly, what can be done to prevent them.” 8

This is a lovely sentiment, but, in terms of demonstrated safety, having your baby on an airplane is probably your best bet.

1. Why Errors Occur. The Perinatal Nurse’s Guide to Avoiding a Lawsuit. Patricia M.Connors, RNC,MS,WHNP. Copyright @ 2009. PESI HealthCare. P.1 2 Examining the Relationship Between Nurse Fatigue, Alertness, and Medication Errors. Farag, Amany et.al. West J Nurs Res. 2014 Apr;(46(4): 288-295.

2. Examining the Relationship Between Nurse Fatigue, Alertness, and Medication Errors. Farag, Amany et.al. West J Nurs Res. 2014 Apr;(46(4): 288-295.

3. Ibid Amany et. al. p. 289.

4. The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout. AORN JOURNAL, June 2008, VOL 87, NO 6. P. 1191.

5. The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout. Connie Garrett, RN, BSN, CNOR. AORN JOURNAL, June 2008, VOL 87, NO. 6, p.1191.

6. American Nurses Association, Nurse Fatigue. See also: ACNM Position Statement: Fatigue, Sleep Deprivation, and Safety.

7. Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing/Volume 32, Issue 17-18/ p. 5445-5460. Tracey Bell, RN RM BA (hons)MA.et al. January 27, 2023.

8. Dr. Lucian Leape: To err is human: Building a safer health system. Washington, DC: National Academy of Science, 1999.

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