Page 1 of 1

Chapter 46. Fatigue, Sleepiness, and Medical Errors (continued)


1. Leape LL. Error in medicine. JAMA 1994;272:1851-1857.

2. Krueger GP. Fatigue, Performance, and Medical Error. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, N.J.: L. Erlbaum Associates; 1994:311, 326.

3. Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press;2000.

4. Lagnado L. Hospitals overwork young doctors in New York. Wall Street Journal May 19, 1998, 1998.

5. Marcus CL, Loughlin GM. Effect of sleep deprivation on driving safety in housestaff. Sleep 1996;19:763-766.

6. Schwartz AJ, Black ER, Goldstein MG, Jozefowicz RF, Emmings FG. Levels and causes of stress among residents. J Med Educ 1987;62:744-753.

7. Small GW. House officer stress syndrome. Psychosomatics 1981;22:860-869.

8. Rosekind MR, Gander PH, Gregory KB, et al. Managing fatigue in operational settings 1: Physiological considerations and counter-measures. Hosp Top 1997;75:23-30.

9. Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep 1996;19:318-326.

10. Koslowsky M, Babkoff H. Meta-analysis of the relationship between total sleep deprivation and performance. Chronobiol Int 1992;9:132-136.

11. Cox T K, GP, ed. Stress and Sustained Performnace 1 ed;1989. Work and Stress;No. 3.

12. Krueger G, ed. Sustained work, fatigue, sleep loss and performance: A review of the issues. 1 ed;1989. Work and Stress;No. 3.

13. Coffey LC, Skipper JK, Jr., Jung FD. Nurses and shift work: effects on job performance and job-related stress. J Adv Nurs 1988;13:245-254.

14. Mitler MM, Carskadon MA, Czeisler CA, Dement WC, Dinges DF, Graeber RC. Catastrophes, sleep, and public policy: consensus report. Sleep 1988;11:100-109.

15. Rosekind MR, Gregory, K.B., Miller, D.L., Co EL, Lebacqz, J.V. Aircraft Accident Report: Uncontrolled Collision with Terrain, American International Airways Flight 808, Douglas DC-8, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18,1993: National Transportation Safety Board; 1994.

16. Wylie CD, Shultz, T., Miller, J.C. Commercial motor vehicle driver fatigue and alertness study. Essex Corporation;October 1996.

17. Akerstedt T, Levi L. Circadian rhythms in the secretion of cortisol, adrenaline and noradrenaline. Eur J Clin Invest 1978;8:57-58.

18. Salvendy G. Handbook of human factors and ergonomics. 2nd ed. New York: Wiley;1997.

19. Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med 1994;24:928-934.

20. Smith-Coggins R, Rosekind MR, Buccino KR, Dinges DF, Moser RP. Rotating shiftwork schedules: can we enhance physician adaptation to night shifts? Acad Emerg Med 1997;4:951-961.

21. Akerstedt T, Torsvall L. Shift work. Shift-dependent well-being and individual differences. Ergonomics 1981;24:265-273.

22. Akerstedt T, Kecklund G, Knutsson A. Manifest sleepiness and the spectral content of the EEG during shift work. Sleep 1991;14:221-225.

23. Akerstedt T. Sleepiness as a consequence of shift work. Sleep 1988;11:17-34.

24. Tucker P, Smith L, Macdonald I, Folkard S. Shift length as a determinant of retrospective on-shift alertness. Scandinavian Journal of Work, Environment and Health 1998;24 Suppl 3:49-54.

25. Green MJ. What (if anything) is wrong with residency overwork? Ann Intern Med 1995;123:512-517.

26. Daugherty SR, Baldwin DC, Jr., Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA 1998;279:1194-1199.

27. Harvey R, Jarrett PG, Peltekian KM. Patterns of paging medical interns during night calls at two teaching hospitals. CMAJ 1994;151:307-311.

28. Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med 1988;318:771-775.

29. New York State Health Code. Section 405;1989.

30. DeBuono BA, Osten WM. The medical resident workload: the case of New York State. JAMA 1998;280:1882-1883.

31. Education ACfGM. Percent of programs cited for work hours 1999 and 2000. Accreditation Council for Graduate Medical Education;2001 May 9 2001.

32. Li J, Tabor R, Martinez M. Survey of moonlighting practices and work requirements of emergency medicine residents. Am J Emerg Med 2000;18:147-151.

33. McCue JD, Janiszewski M, Stickley WT. Residents' views of the value of moonlighting. Arch Intern Med 1990;150:1511-1513.

34. Majidian AM, Brinker MR, Rice JC, Kerstein MD. Moonlighting in a university surgical training program. South Med J 1993;86:441-446.

35. Hunt KR, Hillman BJ, Witzke DB. Moonlighting during the radiology residency. Invest Radiol 1992;27:978-983.

36. Chalian AA, Kagan SH. Backside first in head and neck surgery?: preventing pressure ulcers in extended length surgeries. Head Neck 2001;23:25-28.

37. Greenberg MS. Handbook of Neurosurgery. Vol 4. Lakeland, Florida: Greenberg Graphics, Inc.;1997.

38. Samkoff JS, Jacques CH. A review of studies concerning effects of sleep deprivation and fatigue on residents' performance. Acad Med 1991;66:687-693.

39. Gold DR, Rogacz S, Bock N, et al. Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. Am J Public Health 1992;82:1011-1014.

40. Hawkins MR, Vichick DA, Silsby HD, Kruzich DJ, Butler R. Sleep and nutritional deprivation and performance of house officers. J Med Educ 1985;60:530-535.

41. Hart RP, Buchsbaum DG, Wade JB, Hamer RM, Kwentus JA. Effect of sleep deprivation on first-year residents' response times, memory, and mood. J Med Educ 1987;62:940-942.

42. Rubin R, Orris P, Lau SL, Hryhorczuk DO, Furner S, Letz R. Neurobehavioral effects of the on-call experience in housestaff physicians. J Occup Med 1991;33:13-18.

43. Robbins J, Gottlieb F. Sleep deprivation and cognitive testing in internal medicine house staff. West J Med 1990;152:82-86.

44. Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 1998;352:1191.

45. Denisco RA, Drummond JN, Gravenstein JS. The effect of fatigue on the performance of a simulated anesthetic monitoring task. J Clin Monit 1987;3:22-24.

46. Reznick RK, Folse JR. Effect of sleep deprivation on the performance of surgical residents. Am J Surg 1987;154:520-525.

47. Deaconson TF, O'Hair DP, Levy MF, Lee MB, Schueneman AL, Codon RE. Sleep deprivation and resident performance. JAMA 1988;260:1721-1727.

48. Weinger MB, Vora, S. Hendon, C.N., Howard, S.K, Smith, B.E., Mazzei, W.J., Rosekind, M.R., Gaba D.M. Evaluation of the Effects of Fatigue and Sleepiness on Clinical Performance in On-call Anesthesia Residents During Actual Nighttime cases and simulated cases. Paper presented at: Evaluating Patient Safety and Reducing Errors in Health Care;November 8-10, 1998, 1998;Rancho Mirage, CA.

49. Haynes DF, Schwedler M, Dyslin DC, Rice JC, Kerstein MD. Are postoperative complications related to resident sleep deprivation? South Med J 1995;88:283-289.

50. H�necke K, Tiedemann S, Nachreiner F, Grzech-Sukalo H. Accident risk as a function of hour at work and time of day as determined from accident data and exposure models for the German working population. Scandinavian Journal of Work, Environment and Health 1998;24 Suppl 3:43-48.

51. Axelsson J, Kecklund G, Akerstedt T, Lowden A. Effects of alternating 8- and 12-hour shifts on sleep, sleepiness, physical effort and performance. Scandinavian Journal of Work, Environment and Health 1998;Vol 24 Suppl 3:62-68.

52. Lowden A, Kecklund G, Axelsson J, Akerstedt T. Change from an 8-hour shift to a 12-hour shift, attitudes, sleep, sleepiness and performance. Scandinavian Journal of Work, Environment and Health 1998;24 Suppl 3:69-75.

53. Overland DW. Comparison of Effects of Change From 8 to 12 hour shifts on Air Force Aircraft Maintenance Workers. Alabama: Graduate School of Logistics Acquisition Management, Air Force Institute of Technology;1997.

54. Reid N, Robinson G, Todd C. The quantity of nursing care on wards working 8- and 12-hour shifts. Int J Nurs Stud 1993;30:403-413.

55. Todd C, Reid N, Robinson G. The quality of nursing care on wards working eight and twelve hour shifts: a repeated measures study using the MONITOR index of quality of care. Int J Nurs Stud 1989;26:359-368.

56. Smith L, Folkard S, Tucker P, Macdonald I. Work shift duration: a review comparing eight hour and 12 hour shift systems. Occup Environ Med 1998;55:217-229.

57. Todd C, Robinson G, Reid N. 12-hour shifts: job satisfaction of nurses. J Nurs Manag 1993;1:215-220.

58. Fields WL, Loveridge C. Critical thinking and fatigue: how do nurses on 8- &12-hour shifts compare? Nurs Econ 1988;6:189-195.

59. Mills ME, Arnold B, Wood CM. Core-12: a controlled study of the impact of 12-hour scheduling. Nurs Res 1983;32:356-361.

60. Ugrovics A, Wright J. 12-hour shifts: does fatigue undermine ICU nursing judgments? Nurs Manage 1990;21:64A, 64D, 64F-64G.

61. Washburn MS. Fatigue and critical thinking on eight-and twelve-hour shifts. Nurs Manage 1991;22:80A, 80D, 80F-80H.

62. Thomas H, Jr., Schwartz E, Whitehead DC. Eight- versus 12-hour shifts: implications for emergency physicians. Ann Emerg Med 1994;23:1096-1100.

63. Luna TD. Air traffic controller shiftwork: what are the implications for aviation safety? A review. Aviat Space Environ Med 1997;68:69-79.

64. Price WJ, Holley DC. Shiftwork and safety in aviation. Occup Med 1990;5:343-377.

65. Martin TC. Adverse effects of rotating schedules on the circadian rhythms of air medical crews. Air Med J 1995;14:83-86.

66. Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA 1993;269:374-378.

67. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-872.

68. Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care. Arch Intern Med 1991;151:2065-2070.

69. Thorpe KE. House staff supervision and working hours. Implications of regulatory change in New York State. JAMA 1990;263:3177-3181.

70. Holzman IR, Barnett SH. The Bell Commission: ethical implications for the training of physicians. Mt Sinai J Med 2000;67:136-139.

71. Czeisler CA, Moore-Ede MC, Coleman RH. Rotating shift work schedules that disrupt sleep are improved by applying circadian principles. Science 1982;217:460-463.

72. Akerstedt T. Shifted sleep hours. Ann Clin Res 1985;17:273-279.

73. Folkard S. Shiftwork and performance. Paper presented at: Symposium on the Variations of Work-Sleep Schedules, 1981.

74. Knauth P. Speed and direction of shift rotation. J Sleep Res 1995;4:41-46.

75. Comperatore C.A. K, G.P. Circadian rhythm desynchronosis, jet lag, shift lag, and coping strategies. In: A.J. S, ed. Occupational medicine: Shiftwork. State of the art reviews. Philadelphia, PA: Hanley &Belfus; 1990:323-341.

76. Tucker P, Smith L, Macdonald I, Folkard S. Effects of direction of rotation in continuous and discontinuous 8 hour shift systems. Occup Environ Med 2000;57:678-684.

77. Barton J, Folkard S, Smith L, Poole CJ. Effects on health of a change from a delaying to an advancing shift system. Occup Environ Med 1994;51:749-755.

78. Knauth P, Rutenfranz J, Schulz H, et al. Experimental shift work studies of permanent night, and rapidly rotating, shift systems. II. Behaviour of various characteristics of sleep. Int Arch Occup Environ Health 1980;46:111-125.

79. Pilcher JJ, Lambert BJ, Huffcutt AI. Differential effects of permanent and rotating shifts on self-report sleep length: a meta-analytic review. Sleep 2000;23:155-163.

80. Williamson AM, Sanderson JW. Changing the speed of shift rotation: a field study. Ergonomics 1986;29:1085-1095.

81. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999;281:991-999.

82. Friedman L, Benson K, Noda A, et al. An actigraphic comparison of sleep restriction and sleep hygiene treatments for insomnia in older adults. J Geriatr Psychiatry Neurol 2000;13:17-27.

83. Vgontzas AN, Kales A. Sleep and its disorders. Annu Rev Med 1999;50:387-400.

84. Holbrook MI, White MH, Hutt MJ. Increasing awareness of sleep hygiene in rotating shift workers: arming law-enforcement officers against impaired performance. Percept Mot Skills 1994;79:520-522.

85. Monk TH, Folkard, S. Making Shift Work Tolerable. London: Taylor and Frances;1992.

86. Budnick LD, Lerman SE, Nicolich MJ. An evaluation of scheduled bright light and darkness on rotating shiftworkers: trial and limitations. Am J Ind Med 1995;27:771-782.

87. Foret J, Daurat A, Tirilly G. Effect of bright light at night on core temperature, subjective alertness and performance as a function of exposure time. Scand J Work Environ Health 1998;24:115-120.

88. Czeisler CA, Johnson MP, Duffy JF, Brown EN, Ronda JM, Kronauer RE. Exposure to bright light and darkness to treat physiologic maladaptation to night work. N Engl J Med 1990;322:1253-1259.

89. Eastman CI, Boulos Z, Terman M, Campbell SS, Dijk DJ, Lewy AJ. Light treatment for sleep disorders: consensus report. VI. Shift work. J Biol Rhythms 1995;10:157-164.

90. Chesson AL, Jr., Littner M, Davila D, et al. Practice parameters for the use of light therapy in the treatment of sleep disorders. Standards of Practice Committee, American Academy of Sleep Medicine. Sleep 1999;22:641-660.

91. Putcha L DD, Nimmagudda R, Stewart KT, Kripke DF. Chronobiological measurements in astronauts. Sleep Research 1997;26:746.

92. Baker TL. Use of a circadian lighting system to improve night shift alertness and performance at the USNRC's Headquarters Operations Center. Paper presented at: Safety of Operating Nuclear Reactions;September 17-20, 1995, 2001; Seattle, WA.

93. Bullough J, Rea, M.S. Lighting for neonatal intensive care units: some critical information for design. Lighting Research and Technology 1996;28:189-198.

94. Akerstedt T, Torsvall L. Napping in shift work. Sleep 1985;8:105-109.

95. Harma M, Knauth P, Ilmarinen J. Daytime napping and its effects on alertness and short-term memory performance in shiftworkers. Int Arch Occup Environ Health 1989;61:341-345.

96. Gillberg M, Kecklund G, Axelsson J, Akerstedt T. The effects of a short daytime nap after restricted night sleep. Sleep 1996;19:570-575.

97. Nicholson AN, Pascoe PA, Roehrs T, et al. Sustained performance with short evening and morning sleeps. Aviat Space Environ Med 1985;56:105-114.

98. Gillberg M. The effects of two alternative timings of a one-hour nap on early morning performance. Biol Psychol 1984;19:45-54.

99. Dinges DF, Orne MT, Whitehouse WG, Orne EC. Temporal placement of a nap for alertness: contributions of circadian phase and prior wakefulness. Sleep 1987;10:313-329.

100. Taub JM. Effects of scheduled afternoon naps and bedrest on daytime alertness. Int J Neurosci 1982;16:107-127.

101. Bonnet MH, Arand DL. Impact of naps and caffeine on extended nocturnal performance. Physiol Behav 1994;56:103-109.

102. Taub JM, Tanguay PE, Clarkson D. Effects of daytime naps on performance and mood in a college student population. J Abnorm Psychol 1976;85:210-217.

103. Lubin A, Hord DJ, Tracy ML, Johnson LC. Effects of exercise, bedrest and napping on performance decrement during 40 hours. Psychophysiology 1976;13:334-339.

104. Lumley M, Roehrs T, Zorick F, Lamphere J, Roth T. The alerting effects of naps in sleep-deprived subjects. Psychophysiology 1986;23:403-408.

105. Mullaney DJ, Kripke DF, Fleck PA, Johnson LC. Sleep loss and nap effects on sustained continuous performance. Psychophysiology 1983;20:643-651.

106. Matsumoto K. Effects of nighttime naps on body temperature changes, sleep patterns, and self-evaluation of sleep. J Hum Ergol (Tokyo) 1981;10:173-184.

107. Naitoh P, Englund CE, Ryman D. Restorative power of naps in designing continuous work schedules. J Hum Ergol (Tokyo) 1982;11:259-278.

108. Rosekind MR, Graeber, R. C., Dinges, D. F., Connell, L. J., Rountree, M. S., Spinweber C. L., Gillen, K. A. Crew Factors in Flight Operations IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations Moffett Field, California: NASA;1994.

109. Gillberg M, Kecklund G, Akerstedt T. Sleepiness and performance of professional drivers in a truck simulator—comparisons between day and night driving. J Sleep Res 1996;5:12-15.

110. Rosa RR, Bonnet MH, Bootzin RR, et al. Intervention factors for promoting adjustment to nightwork and shiftwork. Occup Med 1990;5:391-415.

111. Reinberg A, Andlauer P, Vieux N, Permanent Commission and International Association on Occupational Health. Scientific Committee on Shift Work. Night and shift work: biological and social aspects : proceedings of the Fifth International Symposium on Night and Shift Work : Scientific Committee on Shift Work of the Permanent Commission and International Association on Occupational Health (PCIAOH) Rouen, 12-16 May 1980. 1st ed. Oxford ; New York: Pergamon Press; 1981.

112. Ferrara M, De Gennaro L. The sleep inertia phenomenon during the sleep-wake transition: theoretical and operational issues. Aviat Space Environ Med 2000;71:843-848.

113. Takahashi M, Arito H, Fukuda H. Nurses' workload associated with 16-h night shifts. II: Effects of a nap taken during the shifts. Psychiatry Clin Neurosci 1999;53:223-225.

114. Ferrara M, De Gennaro L, Bertini M. The effects of slow-wave sleep (SWS) deprivation and time of night on behavioral performance upon awakening. Physiol Behav 1999;68:55-61.

115. Ferrara M, De Gennaro L, Casagrande M, Bertini M. Selective slow-wave sleep deprivation and time-of-night effects on cognitive performance upon awakening. Psychophysiology 2000;37:440-446.

116. Bruck D, Pisani DL. The effects of sleep inertia on decision-making performance. J Sleep Res 1999;8:95-103.

117. Ferrara M, De Gennaro L, Bertini M. Time-course of sleep inertia upon awakening from nighttime sleep with different sleep homeostasis conditions. Aviat Space Environ Med 2000;71:225-229.

118. Jewett ME, Wyatt JK, Ritz-De Cecco A, Khalsa SB, Dijk DJ, Czeisler CA. Time course of sleep inertia dissipation in human performance and alertness. J Sleep Res 1999;8:1-8.

119. Rosekind MR, Smith RM, Miller DL, et al. Alertness management: strategic naps in operational settings. J Sleep Res 1995;4:62-66.

120. James M, Tremea MO, Jones JS, Krohmer JR. Can melatonin improve adaptation to night shift? Am J Emerg Med 1998;16:367-370.

121. Jorgensen KM, Witting MD. Does exogenous melatonin improve day sleep or night alertness in emergency physicians working night shifts? Ann Emerg Med 1998;31:699-704.

122. Wrenn K, Wright S. Melatonin after night shift work. Ann Emerg Med 1999;33:479.

123. Wright SW, Lawrence LM, Wrenn KD, Haynes ML, Welch LW, Schlack HM. Randomized clinical trial of melatonin after night-shift work: efficacy and neuropsychologic effects. Ann Emerg Med 1998;32:334-340.

124. Walsh JK, Muehlbach MJ, Humm TM, Dickins QS, Sugerman JL, Schweitzer PK. Effect of caffeine on physiological sleep tendency and ability to sustain wakefulness at night. Psychopharmacology 1990;101:271-273.

125. Gaba DM. Physician work hours: The "sore thumb" of organizational safety in tertiary health care. Paper presented at: Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care, 1998; Rancho Mirage, CA.

Return to Contents
Proceed to Next Chapter

Current as of July 2001
Internet Citation: Chapter 46. Fatigue, Sleepiness, and Medical Errors (continued). July 2001. Agency for Healthcare Research and Quality, Rockville, MD.