News & Events

New Study in Journal Health Affairs Links Excessive Overtime and Poor

Working Conditions to an Increase in Medication Errors by Nurses
Report Underscores Need for Passage of Safe RN Staffing Bill

View study in .pdf format

Yet another study was published today linking poor staffing conditions in hospitals to poor care for patients. In this case, a new study in the journal Health Affairs shows a significant increase in medication errors by nurses who work overtime. The report, one of a series of scientific studies published in the last year, provides further evidence in support of legislation pending in Massachusetts to ban mandatory overtime and to establish safe RN staffing levels in Massachusetts hospitals.

Nurses who worked shifts lasting at least 12.5 hours were three times more likely to commit an error, such as giving a patient the wrong medicine or the wrong dose, than nurses who worked less than 8.5 hours, according to the study from the University of Pennsylvania School of Nursing.

Here are some key excerpts from the study:

"The errors nurses reported in this study occurred in the context of well-documented deficiencies in nurses’ practice conditions in U.S. hospitals, deficiencies that nurses have been reporting for well over a decade. The long and unpredictable hours documented here suggest a link between poor working conditions and threats to patient safety."

"More specifically, physiological factors such as fatigue, system variables such as increased work intensity, or a combination of fatigue and increased work intensity may contribute to the errors and near errors we observed. It is also possible that heavy workloads themselves may increase the risk of making an error."

"Our analysis showed that work duration, overtime, and number of hours worked per week had significant effects on errors. The likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting of 12.5 hours or more. Working overtime increased the odds of making at least one error, regardless of how long the shift was originally scheduled."

"The use of mandatory overtime to cover staffing vacancies is a controversial and potentially dangerous practice. More than one-quarter of nurse participants (28.7 percent) reported working mandatory overtime at least once during the data-gathering period, a percentage that is quite similar to that reported in two surveys of more than 47,000 nurses and in a "Quick Poll" posted on the American Association of Critical Care Nurses Web site."

Nurses reported that they committed errors on 103, or five percent, of the 2,057 longer shifts reported and made near errors on 97 of those longer shifts. Near errors are errors nurses intercepted before they reached patients, such as bringing the wrong medication to a patient’s bedside but catching the mistake before injecting it. Meanwhile, nurses made errors on just 12, or 1.6 percent, of the 771 regular shifts, and near errors on only 20 of those shifts.

The findings of this new study echo those of a similarly comprehensive analysis of the issue by the Instituted of Medicine published in November of 2003, which featured an entire chapter on the practice in its groundbreaking report, "Keeping Patients Safe: Transforming the Work Environment of Nurses." The report concluded that long work hours pose one of the most serious threats to patient safety, as fatigue slows reaction time, saps energy, and diminishes attention to detail. The group said that state regulators should pass laws barring nurses from working more than 12 hours a day and went so far as to recommend that patients and their families be notified when care was being provided under these conditions so they could seek alternative care. A copy of the executive summary of this report is available upon request.

In 2001, the Massachusetts legislature convened a Special Legislative Commission on Nursing Practice, which spent many months studying the state of nursing in the Commonwealth. The Commission issued a report that characterized nursing in Massachusetts as a public health "crisis," and its report included recommendations for legislation to ban mandatory overtime and establish safe RN-to-patient ratios. A copy of the Commission report is available upon request.

Background on Mandatory Overtime Issue
Mandatory overtime is a dangerous practice employed by hospital administrators to cut costs by reducing nurse staffing levels and then forcing the remaining nurses to work extra hours and shifts to compensate for the lack of staff. The rise in mandatory overtime began in the mid 1990s, long before there was a purported "shortage" of nurses, after massive layoffs of nurses by hospitals. In fact, Massachusetts cut its hospital nursing staff by more than 27% in the 90s, more than any state in the nation. Between 1994 and 2000, many hospitals in the state began employing mandatory overtime as a standard staffing mechanism, leading nurses in unionized hospitals to cast nine strike authorization votes over the issues of poor RN-to-patient ratios and the resulting increased reliance on mandatory overtime. Nurses at two hospitals in Massachusetts were driven to wage historic strikes over these issues. The nurses at St. Vincent Hospital in Worcester engaged in a 49-day strike in 2000 over the issue; and the nurses at Brockton Hospital waged a 103-day strike. Both strikes were settled with agreements granting nurses the right to refuse mandatory overtime and with language obligating the hospitals to fully staff their facilities to prevent the practices.

H. 1282, Safe RN Staffing Legislation is Key to Solving the Problem

In keeping with the recommendations of the Institute of Medicine and the legislature’s Nursing Commission, health care advocates in Massachusetts are pushing legislation, H. 1282, a bill to establish regulations requiring appropriate RN staffing in Massachusetts hospitals, which would also ban the practice of mandatory overtime. The measure has won the support of more than 70 leading health care and consumer groups, and has been co-sponsored by 102 of 200 legislators, and it is currently being considered by the House Ways and Means Committee. For more information call David Schildmeier at 781.249.0430.