Physician fatigue and other conditions leading to medical errors and adverse drug events (ADEs) are not a new problem challenging healthcare providers. Medical errors are the third leading cause of death in the US and avoidable ADEs are among the most common of these errors. There are a multitude of factors hospitals must address to reduce the risk of medication-related errors and research is still being done to help understand and minimize the impact these factors have on patient safety.
In the past year, COVID-19 has further taxed healthcare resources and I have seen increased stress and fatigue as a result. Hospitals are responding to the increased patient load from COVID-19 by cancelling elective procedures, increasing equipment and resources, and reassigning physicians to intensive care units (ICU) without appropriate training. The strain on healthcare providers due to COVID-19 caused redeployments, overwork, and increased stress. In a survey conducted in April 2020, 64 percent of healthcare workers reported some level of anxiety and 46 percent reported depressive symptoms.
I was able to further explore the impact of fatigue on prescribing behavior as part of a research study in collaboration with the Medical School at Tel Aviv University. The Journal of American Medical Informatics Association (JAMIA) recently released the results of the five-year study, which found important correlations between physician fatigue, work overload, and erroneous prescribing. The research found three primary causes of prescriber error, which I’ve expanded upon in the following as they each deserve additional mention given the environment healthcare providers find themselves in today.
With the high demand for healthcare workers, it is common for physicians to work several successive shifts, defined as multiple 8-hour increments. All prescriptions studied in the JAMIA study were issued by physicians on their second successive shift 32 percent of the time and their third successive shift 14 percent of the time.
According to the study, physicians are more than twice as likely to err during their second or third successive shift than in their first shift. This error rate is progressive, as physicians in their third successive shifts have a 17 percent higher chance to err compared to those in their second shift. In particular, the percent of lab results-dependent errors and pre- and post-prescribing evolving ADEs and contraindications following med-lab and med-vital risks increased noticeably for each successive shift worked.
It has been understood that physicians with longer work hours make more mistakes. A study conducted in 2009 by The Institute of Medicine found a relationship between long hours and risk of injury. Unfortunately, the safeguards and processes needed to reduce these risks have been slow to keep up. It’s expected that smart systems and tools will close the gap in oversight that formerly belonged to humans but is currently missing due to a rapidly evolving healthcare system and impossible expectations of care providers.
There’s a direct relationship between patient velocity per shift and risk of erroneous prescribing. When physicians see more patients and issue more prescriptions in a shift, the risk of an error increases. Physicians experienced work overload in 22 percent of the shifts studied. Under these conditions, physicians were 8.2 times more likely to make a prescription error with the risk increasing from 0.63 percent to 5.19 percent.
Yet, understaffed hospitals must frequently rely on their healthcare workers to attend to more patients. This is especially true when the hospital experiences unexpectedly high occupancy or when systems or processes make work less efficient. While there are guidelines for the number of average weekly work hours, it is more difficult to track and limit the number of prescriptions a physician will issue per shift.
There’s a direct correlation between the duration of a physician’s shift, the number of prescriptions filled during that time, and the number of prescribing errors attributed to the physician.
Physician fatigue increased significantly in 2020 due to the COVID-19 pandemic. A recent study on the role of fatigue during COVID-19 found a significant increase of physician burnout and hopelessness. The increase is even higher for other healthcare workers, such as nurses and technicians.
A separate study found 44 percent of physicians suffered from some level of burnout. Stress, both physical and emotional, affects the quality of patient care and is found as a significant contributor to medication errors.
Hospitals rely on electronic health records (EHR) and drug-drug interaction (DDI) tools to reduce the risks from providers working longer hours and who have less prescribing experience. Unfortunately, even the leading EHR solutions are missing one-third of dangerous medication safety risks. This highlights the importance of incorporating probabilistic and personalized decision support tools which can reduce medication-related risks and harm, and improve patient safety.
The JAMIA study leveraged MedAware’s medication-related risk detection solution to identify patient-specific and provider-specific risk of erroneous prescribing. As the demands on prescribers and healthcare providers increase, AI-enabled clinical decision support solutions can be safely and seamlessly embedded within existing IT ecosystems to provide an additional safety layer while realizing more value from the EHR and DDI knowledge base. Doing so will allow providers to prescribe more confidently, practicing at the top of their education regardless of their shift schedule.