Health care workers and medical errors: the need for a multipronged experimental approach

Citation:

Baddam S. Health care workers and medical errors: the need for a multipronged experimental approach. J Clin Sleep Med. 2020;16(6):841–842.

In this issue of the Journal of Clinical Sleep Medicine, the paper by Ayas et al¹ reports results from a retrospective analysis focusing on consecutive 12-hour shifts and the risk of hypoglycemia in the intensive care unit. This article adds to the research on health care workers’ sleep and on medical errors within the hospital system. Sleep in the intensive care unit and among medical professionals is significant considering health care professionals’ increased work hours during the current coronavirus disease 2019 (COVID-19) pandemic.

Ayas et al’s findings are consistent with the previous research on health care workers’ shifts, sleep, and medical outcomes.¹ Previous research focused on residents showed extended work hours are associated with medical errors and adverse outcomes. Based on this research, the Accreditation of Graduate Medical Education limited interns’ shifts to a maximum length of 16 hours. The adverse effects of extended work hours on patient care and resident education were strongly debated, resulting in a reversal of duty-hours’ restrictions to a maximum of 28 hours in 2017.² This and previous studies have inconsistencies in their research. Three pertinent aspects of the current article and sleep literature in health care workers will be discussed and should be taken into account for future research.

First, in the current study by Ayas et al, sleep debt was extrapolated from health care workers’ scheduled work hours.¹ Similarly, measures of attention and cognition were not utilized because of the nonexperimental research settings. Because of a lack of objective sleep patterns and sleep debt, the association between sleep deprivation and medical errors (hypoglycemic episodes in the study by Ayas et al) cannot be directly made. Additionally, another study on nurses observed that poor sleep quality increased nurses’ medical errors.³ Similarly, the variability in individuals’ circadian rhythms⁴ may affect medical errors.

Second, in health care settings—particularly the intensive care unit—high workload, low staffing, and stress are adversely associated with patient safety.⁵ Nurses with shifts exceeding 10 hours were identified to have higher rates of burnout and reduced reported well-being.⁶ These human factors—stress and emotional well-being—are not routinely assessed in studies of health care workers’ sleep and medical outcomes. Ayas et al’s research agrees with other studies that find shift handovers are consistently associated with higher medical errors. Individual vulnerability to sleep loss is important to assess in order to identify the effects of sleep disruption on workplace errors.

Third, experimental studies with control samples and randomized design are crucial to identify the role of sleep disruption in specific medical errors and medical outcomes.

There is a substantial amount of literature on sleep and medical errors in nurses, residents, and physicians. Previous research has led to fewer changes in workplace schedules, and the research evidence on workplace interventions is weak.⁷ Previous research studies’ lack of objective sleep and human factor measurements, along with less rigorous scientific methodology, have led to variable results. Future research should include specific measures of sleep duration, quality, and circadian rhythms; vigilance and cognition; and stress and emotional well-being in order to identify the clear role of sleep disruption on medical errors.

DISCLOSURE STATEMENT

The author has seen and approved the manuscript. The author reports no conflicts of interest.