The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout

CONNIE GARRETT, RN, BSN, CNOR

ittle disagreement exists about the relationship between nurse staffing levels and patient outcomes in health care settings. Higher staffing levels have been shown to result in better patient outcomes compared with lower nurse staffing levels.1-15 Various measures such as managed health care and reduced reimbursement from insurance companies have combined with the nursing shortage to lead hospital administrators to rely on voluntary and mandatory overtime to solve their nurse staffing problems. According to a 2007 report published by the Agency for Healthcare Research and Quality (AHRQ),16 chronic fatigue and poor global sleep quality (ie, a measure of sleep quality that includes indicators such as time needed to fall asleep, sleep duration, waking up during the night, use of sleeping medication, and difficulty staying awake during the day17) are common among health care personnel. Voluntary overtime requests may be made too often of nurses who do not have families or who suffer financially because of low salaries in nursing,18 and working overtime can lead to dangerous levels of fatigue. On July 4, 2006, Julie Thao, RN, a veteran obstetrical nurse in Wisconsin, worked two eight-hour shifts back to back. Thao slept on a cot at the hospital overnight and was near the end of her shift on July 5 when she administered the wrong medication to a patient, which resulted in a fatal medication error. She was charged with a felony, criminal neglect of a patient causing great bodily harm, the sentence for which is three years on probation and mandatory exclusion from working in a critical care setting. She ultimately pled
AORN, Inc, 2008

no contest to two misdemeanors.19 This was the first time a nurse in Wisconsin had been criminally charged for a medical error.20 The human error component of medical errors18 may be affected by staffing patterns. Although few studies on the topic have been conducted with hospital personnel, studies outside the field of health care demonstrate a relationship between fatigue and degradation in performance. Fatigue has been shown to result in slowed reaction time and lapses of attention to detail that can result in errors of omission, which are known to compromise problem solving, reduce motivation, and decrease energy for successful completion of required tasks.21 Fatigue has been implicated in disasters such as the Exxon Valdez, Bhopal, Chernobyl, and Three Mile Island.22 The working hours for airline pilots and air traffic controllers are regulated to reduce

ABSTRACT
HOSPITAL ADMINISTRATORS frequently rely on the use of mandatory or voluntary overtime to cover staff nurse vacancies. This practice is common in the perioperative setting, but it can lead to staff-member fatigue that may adversely affect patient safety. THIS LITERATURE REVIEW explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout. THE EVIDENCE INDICATES that inadequate nurse staffing leads to adverse patient outcomes and increased nurse burnout. Hospital administrators should invest in adequate nurse staffing to improve patient safety and increase nurse retention. AORN J 87 (June 2008) 1191-1204. AORN, Inc, 2008.

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The perioperative setting is unique in that nurses not only consider it normal to work more than 40 hours a week but also are required to take call, which may result in fatigue. The effects of extreme fatigue can be compared to being under the influence of alcohol.

erative personnel sometimes refer to staffing in the surgical suite as Russian roulette regarding who will have to stay late to act as the circulating nurse in a procedure that has not finished by the shift change. Often, a circulating nurse expects a request to stay late to finish the procedure when there is no available relief. If the nurse objects to staying late, the situation becomes one of mandatory overtime because the nurses preferences do not change the fact that no relief is available. Unrealistic workload may result in chronic fatigue and poor global sleep quality. The literature provides examples of overtime use resulting in fatigue, burnout, absenteeism, and job dissatisfaction among hospital nurses.2,24 In addition, working overtime has been shown to increase the odds of nurses making at least one medication-related error, and the risk of making errors increased for nurses who worked overtime after long shifts.17

the possibility of human error brought on by fatigue. To improve patient outcomes and reduce medical errors, nurse staffing patterns also should be reviewed to ensure that direct patient care is not compromised by the use of mandatory overtime to cover staffing shortfalls.23 This literature review explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout.

FATIGUE
Fatigue is a contributing factor for nurse absenteeism, burnout, and job dissatisfaction.2,24 In addition, rotating shifts and extended work hours of 12.5 hours or more have been shown to increase injuries and automobile accidents among nurses,25 and chronic fatigue has been found to result in depression and poor global sleep quality.18 Minimal data, however, are available in the perioperative setting related to fatigue and increased errors. The perioperative specialty is unique in that nurses not only consider it normal to work more than 40 hours a week but also are required to take call, which may be abused to the extent that the effects of a nurses fatigue can be compared to being under the influence of alcohol. Research has shown that after 17 hours without sleep, performance degrades to the equivalent of having a blood alcohol concentration of 0.05%,21 and after 24 hours without sleep, the effect on performance is equivalent to a blood alcohol level of 0.10%.26 Call hours may vary from four hours to 72 hours or more, though actual hours worked during the call period are unpredictable and can range from 30 minutes to the entire length of the call period.27 A normal day for a perioperative

OVERTIME
In many perioperative settings, mandatory overtime is used daily to staff the OR for elective, unplanned, and emergent procedures or to cover staff nurse vacancies.1 There seems to be a double standard in some ORs when the first day shift is relieved of duty and the shift change occurs. Staffing is usually at the highest level in the morning and decreases as the day progresses to the second shift, possibly as the result of a belief that the perioperative area is not as busy in the afternoon and therefore staffing can be decreased for the second shift. This situation creates a problem of voluntary overtime at the shift change resulting from delayed start times, underestimation for the length of a procedure, and changes in patient status or the complexity of a procedure. Periop-

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A study by Rogers et al1 examined the relationship between medical errors and both staff work patterns and hours worked by nurses. The researchers found that mandatory overtime was NURSE BURNOUT used frequently to cover hosUnrealistic workloads in pital nurse staffing vacancies. the perioperative setting, This policy produces fatigue Mandatory overtime including call, are the result of and nurse burnout, which a shortage of nurses and can ultimately results in more frequently is used to lead to increased absenteeism mandatory overtime to solve and high rates of nurse burnstaffing issues, a practice that cover staff vacancies. out that exceed the norm for is both controversial and health care workers.28 Job dispotentially dangerous.31-33 This results in fatigue satisfaction for nurses is four The study by Rogers et al times higher than the average included 393 RNsmost of and nurse burnout and, rate for all US workers, and whom were womenwho ultimately, in more one in five nurses have worked full time. More than reported that they intend to half worked in hospitals with mandatory overtime to leave their current jobs within 300 beds or more, 56% a year.28 Nurses often cope worked in urban areas, 19% solve staffing issues. worked in suburban areas, with increased stress and 18% worked in small town burnout by calling in sick, and hospitals, and 17% worked in patient safety is compromised rural areas.1 The nurses were by the effect of high nursing 18 turnover rates. Perioperative given logbooks to track their nurse turnover rates increase when nurses scheduled work hours, overtime, days off, burn out and leave the OR to work in other sleep and wake cycles, and errors and near nursing specialties where call is not required errors for 28 days; the logbooks also provided or used as a staffing solution. the opportunity to describe the errors. AlAccording to the American Hospital Assothough the response rate was lower than usual ciation, the current nursing shortage reflects for this type of nurse survey, the lower refundamental changes in population demosponse rate was attributed to the increased graphics, career expectations, work attitudes, effort required for the nurses to record 17 to 40 and worker dissatisfaction.29(p80) Hospital items each day for 28 days. The researchers nursing vacancies are expected to reach took care in the collection of data to ensure 800,000 (ie, 29%) by the year 2020. An expectthat participants identities were protected and

nurse who is on call consists of an eight-, 10-, or 12-hour shift. Nurses on call then may have to work call hours to complete or relieve for elective procedures that are scheduled to start when there are no other available RNs to fill the role of circulating nurse. It is not unusual for the oncall nurse to complete elective cases and continue working for up to 16 hours without rest or relief. That same nurse must then hope that he or she is not called back for an emergency procedure in the middle of the night, which interrupts the sleep cycle and circadian rhythms. The cycle of fatigue starts when the nurse, whether called in the middle of the night to work an emergency procedure or not, is expected to be back at work the next morning at the start of his or her daily shift.

ed 6% increase in the number of nurses by the year 2020 will not keep up with the 40% expected growth in demand. In addition, the elimination of perioperative curriculum in nursing schools has contributed to the shortage of available perioperative nurses in the OR.30 Health care facilities cannot afford to have their perioperative nurses burn out and leave the perioperative setting, so hospital administrators should look for ways to increase nurse retention.

STAFFING PATTERNS

AND

MEDICAL ERRORS

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to alleviate fears related to reporting errors. The nurses in the study generally worked more than 40 hours per week and longer than their scheduled shifts: 39% of the shifts worked lasted 12.5 or more consecutive hours, 14% of the nurses reported working 16 or more hours at least once during the study period, and the longest shift reported was 23.6 hours. The nurses reported working 360 shifts of mandatory overtime, and nurses were coerced to work voluntary overtime for 143 shifts.

PATIENT-TO-NURSE RATIOS, ADVERSE OUTCOMES, AND NURSE RETENTION

A study by Aiken et al2 examined the association between patient-to-nurse ratios and patient mortality, failure to rescue among surgical patients, and factors related to nurse retention. A cross-sectional analysis was performed on linked data from nurses surveyed (N = 10,184) and patients discharged from the hospital (N = 232,342) between April 1, 1998, and November 30, 1999. The researchers found that after adjusting for patient characteristics and hospital characteristics such as size, teaching status, and availability of advanced technology, each additional patient per nurse was associated with a 7% increase in the odds of failure to rescue and a 7% increase in the likelihood of 30-day mortality. Furthermore, each additional patient per nurse was associated with a 23% increase in the odds of nurse burnout and a 15% increase in the odds of job dissatisfaction. This study provides evidence that a high patient-to-nurse ratio is directly responsible for nurses job-related burnout and job dissatisfaction. Aiken et al suggest that hospitals can avoid low nurse retention rates and preventable patient mortality by investing in RN staffing. This study provides the necessary evidence that nurse staffing ratios are major indicators when hospital mortality is used as a variable. The authors suggest that the approach California has taken in legislating nurse staffing to reduce patient mortality is credible, and they agree with government officials decisions to reject hospital stakeholders support of up to 10 patients to each nurse. The ratios mandated in the legislation were five or six patients per nurse on medical and surgical units, depending on the phase of implementation.34

Health care facilities can avoid preventable patient mortality and low nurse retention rates by investing in RN staffing.

During the data-gathering period, 199 errors and 213 near errors were reported, with medication errors accounting for more than half of the total errors. Other errors included procedural, charting, and transcription errors, as well as 6% of errors and 29% of near errors that could not be categorized. Of the respondents, 30% reported making at least one error and 32% reported making at least one near error. Analysis of the data indicated that work duration, overtime, and number of hours worked per week had significant effects on errors, with the likelihood of making an error increasing with longer work hours. Nurses were three times more likely to make an error when working shifts that lasted 12.5 hours or more. Regardless of how long the shift was originally scheduled to last, working overtime increased the odds of making at least one error. The data also indicated a trend of increased risk for errors when nurses worked overtime after longer shifts, with the risks being significantly elevated for overtime worked after a 12-hour shift.

NURSES ASSESSMENTS

OF

QUALITY

OF

CARE

Sochalski3 studied the effects of nurse staffing and indicators of nursing care processes on nurses assessments of the quality of nursing care delivered. A mail and telephone survey was designed to collect information including patient load, quality of care, and work environment for nurses in acute care hospitals in Pennsylvania. The nine-page survey

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captured information on nurses work environments and the nurses perceptions of the quality of care delivered. The survey included variables on patient load; tasks left undone during the previous shift; and patient safety problems (eg, frequency of medication errors, patient falls with injuries) during the previous year. Of the nurses who responded to the survey, a total of 8,670 were included in the data analysis. Nurses reported caring for an average of 6.3 patients on general inpatient units and 1.2 patients on intensive care units (ICUs), with an overall average of 5.3 patients across all respondents. An average of 2.1 tasks were left undone at the completion of the last shift, with 40% of nurses reporting three or more tasks left incomplete. Sixteen percent of the nurses reported that medication errors occurred more than rarely in a period of one year, and more than 20% of nurses reported that patient falls with injuries occurred occasionally or frequently during the same period. Regarding quality of care assessments, 25% of respondents rated the care delivered as excellent, and slightly more than 20% rated the care delivered as poor or fair. Analysis of the data showed that as the number of patients assigned to nurses dropped, quality assessments increased and reports of unfinished tasks and patient safety problems decreased, indicating that nurses with lower numbers of patients assigned to them felt that they were providing a higher level of care. This study demonstrates the relationship between workload versus quality of care and how increased workload results in compromised patient safety and unfinished tasks. More importantly, Sochalski asserted that the results of this study indicate that nurses assessments of quality could provide a critical overview of the process of care (ie, the clinical interventions that comprise the nursing care that patients receive). The author discusses several limitations to the study, including that the cross-sectional data do not permit inference of causality and that the analyses suggest associations between workload changes and patient outcomes but are not equipped to provide definitive links. The data are based on self-reports, which

could be biased because of the associated factors of self-reporting and fear of punitive action. In addition, the subjective variable of excellent quality of nursing care also could result in unmeasured bias.

UNIT STAFFING

AND

ADVERSE PATIENT OUTCOMES

The question of what effect nurse staffing patterns have on patient care has stimulated a number of studies that report links between staffing levels on specific units and adverse patient outcomes.4-8 Central line infections (CLIs), pressure ulcers, medication errors, falls, urinary tract infections (UTIs), and respiratory infections are all examples of negative outcomes associated with low staffing levels. Whitman et al9 attempted to identify which units should increase nursing hours based on patient outcomes. The researchers collected data across several different types of hospital units (ie, cardiac and noncardiac ICUs, cardiac and noncardiac intermediate care, medicalsurgical) and then analyzed the data separately for each unit. This study was a secondary analysis of observational data that included 95 patient care units from 10 adult acute care hospitals. Variables included total staff member work hours and nurse-sensitive outcome rates for CLIs, pressure ulcers, medication errors, falls, and restraint application duration rates (ie, duration for use of mechanical restraints). Descriptive statistics were used to summarize all variables, and average monthly rates were calculated. The researchers found no significant relationship between CLI and pressure ulcer rates and staffing hours worked for any of the specialty units. There was, however, an inverse relationship between falls in cardiac intermediate care units and staff hours worked. Medication errors also were inversely related to staff hours worked in the cardiac ICU and noncardiac intermediate care units. The restraint application duration rate was significantly inversely related to staff hours worked only in medical-surgical units. Overall, the results of the Whitman et al study suggest that the effect of staffing on patient outcomes is highly variable across specialty units but, when present, the relationships
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are inversely related, with lower staffing levels reviewed, the dependent variables of shock, resulting in higher rates of all negative outcardiac arrest, UTIs, and pneumonia were all comes. In this study, there was a lack of signifinegative outcomes associated with low nurse cance between CLIs and nurse staffing and pres- staffing levels. sure ulcers and nurse staffing, which differs ADVERSE OUTCOMES. An AHRQ-funded report from other reports4,5 but may be explained by titled The Effect of Health Care Working Conditions methodological differences in determining on Patient Safety35 reviewed 26 studies on nurse staffing hours. This study is consistent with oth- staffing levels and patient safety measures. Many of the studies reviewed found an associaers when variables of fall rates and nurse staffing levels are observed.7,8 In this study, actu- tion between lower nurse staffing levels and al negative outcomes (ie, CLIs, pressure ulcers) various adverse patient outcomes. The largest were not associated with staffing levels, but study of nurse staffing examined the records of staffing was consistently, statis5 million medical patients and tically, and inversely associated 1.1 million surgical patients with falls, medication errors, who had been treated in 1993 and restraint application duraat 799 hospitals.11 The principal tion rates. The small sample findings included that in hosA vast amount of size could explain the lack of pitals with high rates of RN research has found a relationship in those variables staffing, medical patients had that were different from other lower rates of five adverse relationship between studies. patient outcomes (ie, UTIs, Results from this study pneumonia, shock, upper gaslower nurse staffing have a commonality with the trointestinal bleeding, longer others presented in this literahospital stay) than patients rates and higher rates ture review in the finding that in hospitals with low RN staffing can have an impact on staffing. Higher RN staffing of adverse patient nurse-sensitive outcomes. This was associated with a 3% to study is unique, however, in 12% reduction in patients outcomes. that most studies have identiadverse outcomes, depending fied a relationship between on the outcome. Higher staffing patterns and adverse staffing at all levels of nursing outcomes at the hospital level (ie, RNs, licensed practical or on a specific unit, whereas this one reviewed nurses [LPNs], and nurses aides) was associatthe issue across multiple units and then ed with a 2% to 25% reduction in adverse outapplied the data to individual units. The data comes, depending on the outcome. For surgical from this study may help hospital administrapatients, higher rates of RN staffing were associtors anticipate which units need higher levels ated with a 5% to 6% reduction in rates of UTIs, of staffing and at what time of day these higher a 4% to 6% reduction in rates of failure to rescue, levels of staffing are needed, and the data may and an 11% reduction in rates of pneumonia be useful in developing staffing patterns that compared to facilities with low RN staffing. are linked to quality. A study by Unruh12 of acute care hospitals in Pennsylvania found that hospitals with AHRQ REPORTS more licensed nurses had a lower incidence of The AHRQ reports that a vast amount of nearly all of the adverse outcomes studied. A research has shown a relationship between 10% increase in the number of RNs and LPNs lower nurse staffing and higher rates of decreased adverse patient outcomes,10 with two research lung collapse by 1.5%, reports from the AHRQ10,35 presenting evi pressure ulcers by 2%, dence that shows hospital staffing is directly falls by 3%, and related to patient outcomes. In the studies UTIs by less than 1%.12

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PNEUMONIA. Three studies found that lower nurse staffing is directly related to increased rates of pneumonia in particular.13-15 A study by Kovner et al13 found that adding half an hour of RN staffing per patient day could reduce pneumonia in surgical patients by more than 4%. Another study by Kovner et al14 revealed that fewer RN hours per patient were significantly correlated with a higher incidence of pneumonia.

ENSURING PATIENT SAFETY THROUGH ADEQUATE NURSE STAFFING

This literature review included various studies that compared staffing patterns with patient outcomes and explored the relationship of fatigue and nursing errors. The evidence indicates that nurse staffing patterns can have positive and negative effects on patient care, and low levels of nurse staffing can result in medical errors and adverse outcomes. Rather than placing blame on nurses for lapses in patient care, hospital administrators should ensure the safety of patients by examining how health care is provided in their facilities and changing nurses working conditions so that they are able to more safely care for patients. Nurses who suffer fatigue as a result of working mandatory overtime or call are set up for the potential to make medical mistakes, which not only have a negative effect on nurses and their coworkers but also may result in adverse outcomes for patients. Inadequate staffing and unrealistic workloads place an unnecessary burden on nursing staff members, reduce the quality of care that nurses are able to provide, lead to fatigue and unachievable expectations, and result in uncompleted tasks. Physicians also agree with hospital nurses who report that nurse staffing levels are inadequate for safe and effective care and that inadequate nurse staffing is a major impediment to providing high-quality hospital care.36 An AHRQ report10 reveals the financial burden of adverse events, which can raise the cost of total treatment by 84%; for example, this translates to an increase of $22,390 to $28,505 to treat pneumonia. Adverse events also were shown to increase length of stay by 5.1 to 5.4 days and probability of death by 4.67% to 5.5%.10 When adverse outcomes occur as a result of low nurse staffing, placing blame on nurses provides no solution to the problems that managed care and budget cuts have caused. Ensuring an adequate number of nurses to provide good quality patient care is a challenge for many hospitals, but the rewards can be more positive outcomes, higher nurse retention, less nurse burnout, and higher quality patient care.

Instead of placing blame on nurses for lapses in patient care, hospital administrators should ensure patient safety by examining how health care is provided in their facilities and changing nurses working conditions so that they are able to more safely care for patients.

A study by Cho et al15 of nurse staffing and adverse outcomes in California found an 8.9% decrease in the odds of a surgical patient acquiring pneumonia when RNs were available for one additional hour per patient day. This study also showed a 9.5% decrease in the odds of a patient acquiring pneumonia when the proportion of RNs was increased by 10%. The researchers suggested that heavy responsibilities placed on RNs for respiratory care of surgical patients is directly related to rates of RN staffing and pneumonia. Unlike many other studies, these researchers examined only adverse outcomes that were not present at the time of admission.15

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REFERENCES 1. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212. 2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1 987-1993. 3. Sochalski J. Is more better? The relationship between nurse staffing and the quality of nursing care in hospitals. Med Care. 2004;42(2 Suppl):II67-II73. 4. Archibald LK, Manning ML, Bell LM, Banerjee S, Jarvis WR. Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J. 1997;16(11): 1045-1048. 5. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 1996;17(3):150-158. 6. Blegen MA, Vaughn T. A multisite study of nurse staffing and patient occurrences. Nurs Econ. 1998; 16(4):196-203. 7. Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nurs Res. 1998;47(1):43-50. 8. Sovie MD, Jawad AF. Hospital restructuring and its impact on outcomes: nursing staff regulations are premature. J Nurs Adm. 2001;31(12):588-600. 9. Whitman GR, Kim Y, Davidson LJ, Wolf GA, Wang SL. The impact of staffing on patient outcomes across specialty units. J Nurs Adm. 2002;32 (12):633-639. 10. Stanton MW. Hospital nurse staffing and quality of care. Res In Action. March 2004;14:1-10. http:// www.ahrq.gov/research/nursestaffing/nursestaff .pdf. Accessed March 1, 2008. 11. Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and patient outcomes in hospitals. Final report for Health Resources and Services Administration. Boston, MA: Harvard School of Public Health; 2001. 12. Unruh L. Licensed nurse staffing and adverse events in hospitals. Med Care. 2003;41(1):142-152. 13. Kovner C, Mezey M, Harrington C. Research priorities for staffing, case mix, and quality of care in US nursing homes. J Nurs Scholarsh. 2000;32(1): 77-80. 14. Kovner C, Jones C, Zhan C, Gergen PJ, Basu J. Nurse staffing and postsurgical adverse outcomes: an analysis of administrative data from a sample of US hospitals, 1990-1996. Health Serv Res. 2002;37(3): 611-629. 15. Cho SH, Ketefian S, Barkauskas VH, Smith DG. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52(2):71-79. 16. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; July 2001. http://

www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf. Accessed March 1, 2008. 17. Mystakidou K, Parpa E, Tsilika E, et al. The relationship of subjective sleep quality, pain, and quality of life in advanced cancer patients. Sleep. 2007;30(6):737-742. 18. Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse Staffing and Quality of Patient Care. Rockville, MD: Agency for Healthcare Research and Quality; March 2007. http://www.ahrq.gov/down loads/pub/evidence/pdf/nursestaff/nursestaff.pdf. Accessed March 1, 2008. 19. Mason DJ. Good nursebad nurse [Editorial]. Am J Nurs. 2007;107(3):11. 20. Wahlberg D, Treleven E. Nurse is charged in death of patient. Wisconsin State Journal. November 3, 2006:A1. http://www.madison.com/archives /read.php?ref=/wsj/2006/11/03/0611030019.php. Accessed March 1, 2008. 21. Committee on the Work Environment for Nurses and Patient Safety; Board on Health Care Services; Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. http://www.nap .edu/openbook/0309090679/html/1.html. Accessed March 2, 2008. 22. Mitler MM, Carskadon MA, Czeisler CA, Dement WC, Dinges DF, Graeber RC. Catastrophes, sleep, and public policy: consensus report. Sleep. 1988;11 (1):100-109. 23. Beyea SC. Too tired to work safely? AORN J. 2004;80(3):559-562. 24. Zboril-Benson LR. Why nurses are calling in sick: the impact of health-care restructuring. Can J Nurs Res. 2002;33(4):89-107. 25. 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(7):1011-1014. 26. Rosekind M, Gander PH, Gregory KB, et al. Managing fatigue in operational settings 2: an integrated approach. Hosp Top. 1997;75(3):31-35. 27. AORN position statement: Safe work/on-call practices. In: AORN Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007: 409-412. http://www.aorn.org/PracticeResources /AORNPositionStatements/Position_SafeWork OnCallPractices/. Accessed March 6, 2008. 28. Aiken LH, Clarke SP, Sloane DM, et al. Nurses reports on hospital care in five countries. Health Aff (Millwood). 2001;20(3):43-53. 29. AHA Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, IL: American Hospital Association: April 2002. http:// www.aha.org/aha/resource-center/Statistics-andStudies/ioh.html. Accessed March 1, 2008. 30. Girard NJ. Perioperative educationperspective from the think tank. AORN J. 2004;80(5):827-838. 31. Bosek MS. Mandatory overtime: professional duty, harms, and justice. JONAS Healthc Law Ethics
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Regul. 2001;3(4):99-102. 32. Capitulo KL, Ankner ML, Miller J. Professional responsibility versus mandatory overtime. J Nur Adm. 2001;31(6):290-292. 33. Curtin LL. The case against mandatory overtime. Semin Nurse Manag. 2002;10(4):274-278. 34. Governor Davis announces nurse workforce initiative [news release]. Sacramento, CA: Office of the Governor; January 23, 2002. http://psychtechs.net /idx/PSYCH-HEALTH1/nurse02.htm. Accessed March 1, 2008. 35. Hickam DH, Severance S, Feldstein A, et al. The Effect of Health Care Working Conditions on Patient

Safety. Rockville, MD: Agency for Healthcare Research and Quality: May 2003. http://www .ahrq.gov/downloads/pub/evidence/pdf/work /work.pdf. Accessed March 1, 2008. 36. Doctors in five countries see decline in health care quality. Commonw Fund Q. 2000;6(3):1-4.

Connie Garrett, RN, BSN, CNOR, is an OR nurse educator at James A. Haley Veterans Hospital, Tampa, FL.

DASH Diet May Prevent Strokes in Women

he Dietary Approaches to Stop Hypertension (DASH) diet was found to lower the risk of coronary heart disease (CHD) and stroke in middle-aged women, according to a study in the April 14, 2008, Archives of Internal Medicine. The prospective cohort study included 88,517 female nurses, ages 34 to 59 years, with no history of cardiovascular disease or diabetes in 1980. After seven dietary assessments during 24 years of follow up, researchers recorded the following: 2,129 cases of incident nonfatal myocardial infarction, 976 CHD deaths, and 3,105 cases of stroke.

After adjusting for cardiovascular risk factors (eg, age, smoking), researchers found that DASH scores were associated with a significantly reduced risk of stroke in women. The DASH score, based on consumption of certain foods and nutrients (eg, whole grains, low-fat dairy, sodium), was also significantly associated with lower plasma levels of Creactive protein (ie, an indicator of inflammation and stroke risk).
Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med. 2008;168(7):713-720.

US Pharmacopeia Revises Glycerin Monograph

revised glycerin monograph is scheduled for publication in the United States Pharmacopeia as a means to increase consumer safety and prevent fatalities associated with adulteration of the sweetener, according to a March 17, 2008, news release from the US Pharmacopeia (USP). The revised monograph includes an updated procedure for quantifying impurities in glycerin and a new procedure for identifying the presence of diethylene glycol. Diethylene glycol, a poisonous chemical used in industrial solvents and antifreeze, has been found as an adulterant in glycerin, which is used as a sweetener in pharmaceutical syrups and various consumer products. In 1938, more than 100 US citizens died of poisoning from diethylene glycol. Since then, the

USP has worked with the US Food and Drug Administration (FDA) to increase consumer safety. The FDA issued a Guidance for Industry Testing of Glycerin for Diethylene Glycol in May 2007, emphasizing the importance of screening for the chemical. The revised monograph and FDA guidelines require any medication manufacturer using glycerin to prove diethylene glycol is not present in its product. The revised monograph goes into effect on May 15, 2008. The USP currently is working to update additional monographs for ingredients that may also be susceptible to diethylene glycol contamination.
USP announces revised glycerin monograph [news release]. Rockville, MD: US Pharmacopeia; March 17, 2008.

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