A Difficult Time for Patient Safety

For many of you, the end of your clinical workday or shift is jam packed: patient handoffs, reviewing test results, catching up with documentation—maybe even an extra patient encounter to make up for earlier schedule delays. In the midst of these noble efforts to finish your to-do list, however, your performance may be less safe than at other times.

A number of studies indicate that factors such as fatigue, staffing, scheduling, and circadian rhythms can impact end-of-day/shift care: physical skills and cognitive abilities are impaired, teamwork efficiency declines, distractions increase, and systems dependent on off-the-clock staff become more vulnerable. Even your patients, who also experience many of these temporal adversities, may be less engaged and inattentive to important details.

Does that mean that more events that lead to allegations of medical malpractice occur at 4:59 p.m. than at 7:04 a.m.? Frankly, it is hard to tell. While the clinical experts who code the MPL cases in CRICO’s national Comparative Benchmarking System have access to medical and legal records, not everything is revealed. Case files rarely pinpoint an exact moment when a medical mishap occurred (i.e., most cases involve a series of events rather than a single act) and the physical and mental state of the involved clinicians. Factors such as double shifts, schedule snafus, or decision fatigue are also usually out of reach of case investigators.

But within reach is a growing body of evidence about what negatively impacts the performance of health care providers…and when. And it is reasonable to assume that suboptimal performance increases the risk of consequential mistakes. Paying attention to those factors—especially at certain times of the day—is an important step towards reducing the risk of adverse events, patient harm, and allegations of malpractice.

Health Care Studies

• Association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening (JAMA)
  Clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Patient completion of cancer screening tests within one year of the visit was also lower as the primary care appointment time was later in the day.
• Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination (JAMA)
  Influenza vaccination rates significantly declined as the clinic day progressed. The active choice intervention was associated with a significant increase in influenza vaccination rates that were similar in magnitude throughout the day.
• Time of day and the decision to prescribe antibiotics (JAMA)
  Primary care clinicians’ likelihood of prescribing antibiotics for acute respiratory infections increased during clinic sessions, consistent with the hypothesis that decision fatigue progressively impairs clinicians’ ability to resist ordering inappropriate treatments.
• Time of day effects on the incidence of anesthetic adverse events (Quality and Safety in Healthcare)
  Clinical outcomes may be different for patients anesthetized at the end of the work day compared with the beginning of the day. Although this may result from patient related factors, medical care delivery factors such as case load, fatigue, and care transitions may also be influencing the rate of anesthetic adverse events for cases that start in the late afternoon.

Other Studies

• Studies link fatigue and sleep to MLB performance (American Academy of Sleep Medicine)
  Major league baseball players’ strike-zone judgment was significantly worse in September compared with April. The statistical model demonstrated strong predictive value through the season
• Physical and cognitive consequences of fatigue: a review (ScienceDirect)
  Muscle fatigue causes decrease in muscle activation pattern, which in turn affects the joint sense of position leading to disturbed balance and an increase in the risks of falls. Furthermore, fatigue appears to have an effect on cognitive functions […] a relation does exist between the intensity and duration of physical activity and the cognitive function.
• Do 3-point shooters get tired? (ESPN)
  In their first 25 minutes on the court, NBA players shoot 3s consistently, in a tiny, and productive range from 35.6 to 36.8 percent. When players have logged 41–45 minutes, their percentage is 27.9 percent.
• Extraneous factors in judicial decisions (National Academy of the Sciences of the USA)
  The likelihood of a favorable ruling by Israeli parole board judges is greater at the very beginning of the work day or after a food break than later in the sequence of cases.

Additional Materials

• Don’t Visit Your Doctor in the Afternoon