Tuesday, December 13, 2011

Vigilance in the Face of Fatigue

The probe into ventilator deaths undertaken by The Boston Globe points to "alarm fatigue" as a key reason for failure of these systems. However, as the stories from the Detroit Free Press about patient safety concerns at nursing homes point out, there are numerous other "fatigue" issues involved with failure of ventilators and other clinical processes, including overwhelmed staff, under-competent staff, under-armed regulators, and an industry under financial strain.

Vigilance is often the byword we use in steeling ourselves to be watchful for patient safety, however, how do you ensure adequacy of vigilance in the face of fatigue - when the demand for it requires intensity, concentration, time, competence - all of which are at a premium even at the best of times. This is a complex problem which will not go away with exposes, fines, shame, root cause analyses, and disciplining of staff. Its a symptom of a system gone considerably awry, and a distressing illustration of the harm that can occur at the "sharp end".

Overwhelming as the task may seem, the solution will entail a careful redesign of care systems such that staff who care for patients on ventilators have the knowledge, training, experience, time, and support to ensure that they can deliver the care required. Relegating this to another case of "alarm fatigue" may be tempting, but it risks the thinking that we could solve it if only we had better alarms or more attentive staff. Staff will only be able combat the collective fatigue if they are placed into roles that they can manage, and provided with adequacy of workload such that patient care does not suffer.

Despite the mostly impressive drive over the recent decade to improve healthcare quality, we have largely failed to highlight and support adequacy of workload as a foundation of patient safety. All frontline nurses and doctors can readily point out that patient safety starts with a manageable workload. However, these repetitive patient safety failures demonstrate that we keep placing staff in "unsafe" working conditions and somehow expecting good outcomes. The accountability belongs to the leadership not to the staff. This complex problem cannot be addressed by the clinicians on the front lines; rather, it should be a call to leaders to design clinical systems more effectively and to put their staff in situations in which they can succeed.

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