Safety Watch: Fatigue (v4-1)

Download PDF Printable Flyer

The Center for Patient Safety is issuing this notification regarding:


The effects of fatigue include:

  • Lapses in attention and inability to remain focuses
  • Confusion
  • Impaired communication
  • Compromised problem solving
  • Memory lapses


  • Review policies pertaining to off shift hours and consecutive shift work to ensure they address extended work hours
  • Review hand-off processes as they are a time of high patient safety risk
  • Create and implement a fatigue management plan
  • Educate staff on the effects of fatigue on patient safety


  • Ask your staff if they have concerns regarding the effect of fatigue on their care
  • Encourage staff to use teamwork strategies such as second/double checking of critical tasks
  • Consider fatigue as a contributing factor to adverse events during the next Patient Safety Huddle/Briefing



PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More


The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.