2019

Fatigue Risk
Management
Education Toolkit
for JMO Managers and Supervisors

Identify. Assess. Action.

 Table of Contents

Executive Summary 01

Introduction 02

Background 03

Causes of fatigue? 04

What are the common consequences of fatigue? 05

Why is fatigue a problem in healthcare? 06

Implementing a Fatigue Safety Culture 07

Managing Fatigue - A Shared Responsibility 08

Risks & Controls 09

Fatigue Risk Management Tools 10

Fatigue Risk Management Framework 11

Identify - Fatigue 12

Assess - Fatigue 13

Action - Fatigue 14

Fatigue Risk Management Workbook 16

Fatigue Risk Management Case Studies 18

Level 1 - Opportunity to Sleep

Level 1 Case Study: The Roster 19

Tools & Tips for JMO Managers 20

Level 2 - Getting Adequate Sleep

Level 2 Case Study: The Sleep Factor 21

Tools & Tips for JMO Managers 22

Level 3 - Fatigue Signs & Symptoms

Level 3 - Case Study: Take a Break 23

Tools & Tips for JMO Managers 24

 Fatigue Risk Management Toolkit

Level 4 - Fatigue Related Errors

Level 4 Case Study: Prescribing Investigation 25

Tools & Tips for JMO Managers 26

Level 5 - Fatigue Related Incidents

Level 5 Case Study: SAC1 Medication Error 27

Tools & Tips 28

Education & Training

For JMOs, JMO Managers and Clinical Supervisors 29

Ongoing Review & Improvement 30

Fatigue Risk Management Appendices

Appendix 1 - Signs & Symptoms of Fatigue 33

Appendix 2 - Causes & Consequences of Fatigue 34

Appendix 3 - Working Hours Award Table 35

Appendix 4 - HNE Health Roster Design Guidelines 37

Appendix 5 - AMA Risk Assessment Tool 39

Appendix 6 - NSW Health Incident Management System Process 41

Appendix 7 - Reporting Fatigue as a contributing factor in IIMS 42

Appendix 8 - JMO Cab Charge Initiative 44

Other Resources / Support 45

References 46

Acknowledgements 47
 Executive Summary

Delivering healthcare in Australia

is a 24 hour, 7 day process with
Risks that can be proactively
controlled include:
Identify
round-the-clock delivery becoming
1) Identification of fatigue related
a community expectation in all
metropolitan and most rural signs & symptoms
hospitals. Providing that level of care
2) Assessment of the work and
often requires complex rostering
personal factors contributing to Assess
of a finite workforce, notably junior
medical officers (JMOs), to cover fatigue
acute hospital wards and services
3) Actioning improvements to
both day and night.
rostering to provide ample
This educational framework has
been developed to provide JMOs,
opportunity to sleep and rest
Action
clinical supervisors and medical This framework allows the user to
administrators with a suite of practical recognise and respond to signs of
tips and tools that assist with fatigue and lowered alertness, control
identifying and managing fatigue in the associated risks, and potentially
the workplace. It includes a practical prevent a fatigue related incident from
workbook to facilitate learning and occurring. If fatigue is reported as an
understanding of the key elements issue, this should trigger managers
and how they can be applied to suit to action and review controls at each
local needs. level to ensure they are working
sufficiently. Where an error or
The framework is based on a Fatigue incident does occur, the relevant
Risk Management System (FRMS) that investigation must promote a “blame
was implemented across Queensland free” culture where feedback from
Health in 2009, as well as learnings mistakes is provided as an educational
from global mining and aviation opportunity for doctors to improve.
sectors. This framework incorporates a Managing fatigue related risk during
proactive model of 5 ‘levels of control’ junior doctor training years is essential
to manage fatigue related risks and to supporting the dual role of the
hazards. learner and healthcare provider.

Note that within NSW Health, “JMO”

encompasses those working as interns,
residents and registrars (both accredited
and non-accredited trainees).

01 Fatigue Risk Management Toolkit

 Introduction
In November 2017, NSW Health released the The JMO Wellbeing & Support Plan builds
JMO Wellbeing & Support Plan in response on the “Statement of Agreed Principles on
to JMOs expressing that medical training a Respectful Culture in Medicine” initiative
caused significant fatigue, and inadequate to establish support for doctors in training,
emotional and psychological support. This and focus on practical initiatives that
led to the development of a State strategy to can be implemented within the hospital
improve JMO wellbeing and the educational setting. There is particular focus on
training experience for junior doctors. reviewing rostering, implementing initiatives
that address bullying, harassment and
Additionally a national survey of doctors
discrimination, improve the monitoring of
and medical students found that doctors
training and supervision outcomes, and the
reported substantially higher rates of
introduction of safe working hours.
psychological stress and attempted suicide
compared to both the Australian population The NSW health standard is a maximum
and other Australian professional groups. rostered shift length of 14 hours and a break
The Australian Medical Association (AMA), of at least 10 hours between rostered shift
the Australian Salaried Medical Officers periods. This is commonly known as the
Federation (ASMOF), the Black Dog 14/10 rule. The implementation of this system
Institute, local health districts, specialty wide approach will further support and
medical colleges, student associations and monitor standards to ensure rostering best
medical school deans have now agreed to practice.
develop frameworks that address mental
health and wellbeing.

The HNELHD JMO Wellbeing Action Plan has identified 6 key domains for action:

Rostering and Education and

Allocations Training

Overtime Wellbeing

Morale and
Access to Leave
Culture

The Fatigue Risk Management Framework forms part of the wellbeing and rostering domains.

02
 Background

What is Fatigue?

Safe Work Australia defines fatigue as feeling processes in our bodies, such as temperature
more than tired and drowsy. In a work context, control, hormone production, alertness and
fatigue is a state of mind and/or physical sleep. These circadian rhythms run over a period
exhaustion which reduces a person’s ability of approximately 24 hours and are strongly
to perform work safely and effectively. It can influenced by the natural cycles of light and
occur because of prolonged mental or physical dark.
activity, sleep loss and/or disruption of the
At night, many of the processes that are active
internal body clock.
during the day start to slow down as our bodies
Working at night inevitably causes sleep prepare for sleep. The circadian pacemaker
deprivation and fatigue. This is because the also stimulates night-time release of the ‘sleep
human body is designed to sleep at this time. hormone’ melatonin from the pineal gland,
Our bodies are controlled by an internal daily which has the effect of lowering alertness and
body clock, situated in the suprachiasmatic increasing the desire for sleep. Working at night
nucleus (SCN) in the hypothalamus. The SCN involves fighting against these rhythms, and
spontaneously generates the circadian rhythms trying to be alert when you are programmed to
that regulate many physiological and behavioral be asleep.

Melatonin
Level

2 6 8am 9 10 12pm 2 4 8pm 9 10 12am 2

Wake Up Best Best Physical Bed Time

Concentration Performance

Lowest Body Highest Blood Post Lunch Dip/

Temperature Pressure Time for Coffee

03 Fatigue Risk Management Toolkit

 Fatigue Risk Management Toolkit

Causes of Fatigue?

It is important to recognise that there are

many factors that contribute to varying
levels of fatigue. Some of these causes and
consequences can be identified as:
Personal Life and
Wellbeing
JMOs need time to manage other
responsibilities such as family, carer and
social activities. Balance is required to
Rostering ensure that time off duty is effectively
The organisation has a duty to provide managed.
JMOs with a roster that does not require
Employers need to provide opportunity
extended shift length > 14 hours, and
for self-care and wellbeing activities,
provides the opportunity to obtain
exercise and maintaining a healthy work/
sufficient sleep/rest ie >10 hours.
life balance.

Circadian Rhythm Work Environment

The effects of fatigue are most apparent
There are many environmental factors
when working in the latter half of the
that can increase feelings of fatigue.
night, often in a state of acute sleep
deprivation. • Complex and demanding workload

Shift workers fight their body’s natural • Loud, hot/cold, poorly lit work areas
instinct to sleep during the circadian low. • Stress of maintaining a work/life
balance

Sleeping Habits
‘Sleep hygiene’ means habits that help
to improve the quality of sleep at night. Quality of Sleep
Sleep can be dramatically improved The majority of people require 7-9 hours
by making adjustments to lifestyle and sleep per day, which is considered best
behaviors. taken in one single block.
E.g. Going to bed on-time, relaxation Sleep deprivation affects a wide range of
practices, sleep environment, avoiding cognitive functions including attention,
drugs and alcohol. memory and decision making.

04
 Background

What are the Consequences

of Fatigue?
Fatigue has long been known to reduce The likelihood of having a car crash on the way
performance. Working at night reduces home is greater following a night shift than
alertness, vigilance and cognitive reasoning. In after any other shift. Moreover, when doctors
fact, there is now clear international evidence are tired they become less able to judge their
that doctors who are sleep-deprived have more own performance accurately, and may not even
attentional failures and make more clinical realise they are making mistakes.
errors than when they are able to gain adequate
Exhaustion also impairs recent learning and
sleep. Furthermore, 20–25 hours without sleep
decreases the ability of junior doctors to make
reduces psychomotor performance to the level
correct diagnoses. This can have important
of someone with a blood alcohol concentration
implications for both training, patient care and
of 0.10 % which is significantly greater than the
the health service. The combination of fatigue
current maximum level for legal driving.
and a poorly adapted body clock, makes
Evidence from the U.S. shows that doctors who working during the night uncomfortable and
work extended shifts of 24 hours or longer, increases medical errors.
more than double their risk of being involved
For more signs and symptoms of fatigue – See
in a road traffic accident on their journey home
Appendix 1
compared with those working shorter shifts.

• Reaction times • Increased • Anxiety and • Lack of sleep

are slower likelihood of decreased promotes
• Short term social isolation tolerance feelings of
memory and • Impact on • Mood stress
concentration relationships disturbance • Poor physical
decreases • Reduced • More health results
• Communication interactions withdrawn than in anxiety and
issues with family and usual depression

• Falling asleep friends • Increased

• Increased risk • More quiet than stress levels
of clinical error usual

05 Fatigue Risk Management Toolkit

 Fatigue Risk Management Toolkit

Why is Fatigue a Problem in

Healthcare?
Fatigue has now become an accepted by-
product of a 24/7 healthcare system. There are
many work-related and personal factors that
contribute to, and increase the health and safety
risks associated with fatigue. When working
extended night shifts, the body is physically
programmed by circadian rhythms to perform
only basic functions and to sleep. Identifying,
assessing and managing these risks is key to
building a safe working environment.

“Long continuous duty hours, reduced Health

opportunities for sleep with minimal
recuperation time, and shift work all
contributed significantly to impairments
in physical, cognitive, and emotional Safety
functioning. Detrimental effects
include those on personal health and
well being, patient health and safety,
Well-
performance of job-related tasks, and
Being
professionalism” (Owens 2007)

Fatigue degrades all aspects of human outcomes for staff, the organisation, the
performance, leading to reduced safety margins community and patients. It has been found that
and increased operational incidents. Studies errors or injuries in doctors in training were
continue to show a significant link between increased when they worked extended hours.
fatigue and impaired performance. Therefore The risk of occupational sharps injuries, motor
minimising these potential risks has become an vehicle accidents or making a serious medical
essential part of providing safe clinical practice. error increased significantly with hours of duty.

Doctors working more than 80 hours per week Leading causes of death in the U.S.:
have been shown to be 1.6 times more likely to
1) Heart disease
report an adverse patient event or medical error.
2) Cancer
While a certain level of fatigue can be a
normal response to everyday living, high levels 3) Medical Errors
of fatigue can have a range of undesirable

06
 Implementing a
Fatigue Safety Culture

There is no universally accepted definition of JMO Managers need to communicate the safety
a safety culture, but it encompasses the key vision, establish safety priorities and ensure
components of: shared values and beliefs that the implementation of appropriate policies,
interact with an organisation’s structures and procedures and practices. In line with this, JMOs
behavioural norms. How functional and effective need to be given opportunities to change their
the safety culture is in maintaining health and behaviours, to be acknowledged as the expert
safety, will be determined by how strong or on their job; and there must be a mechanism in
positive the organisational culture is. A safety place for JMOs to feedback and communicate
culture can only be successful if employees, their needs.
managers and leaders are engaged and
committed to safety practices.

Leadership
and
Management

Values
Collaboration, Risk
Staff and Management
Organisation Framework
Safety
Culture

Behaviours
Increased Clinical
Awareness of Learning
Safety Roles Environment

How to Create and Communicate a Fatigue Safety Culture

• What’s in it for me? • Who is supporting this initiative?
• Why do we need to focus on fatigue risk • What are the benefits to the organisation
management? and the JMOs?
• Are we capable of managing fatigue?

07 Fatigue Risk Management Toolkit

 Managing Fatigue -
A Shared Responsibility

All stakeholders share responsibility for complying with policies and improving fatigue management.
Everyone has a duty to ensure a safe working environment; work-related causes of fatigue are largely
under the control of the organisation and non-work related factors are controlled by individual
employees, but both have a responsibility for managing fatigue. Employers and employees need to
be aware of the risks posed by fatigue on the job, and take steps to reduce that risk. It is essential that
each group is aware of their roles and responsibilities.

Organisational Responsibility: JMO Responsibility:

• The organisation has a duty to provide • JMOs are responsible for using their allocated
JMOs with a roster that does not require time away from work to obtain sufficient
extended shift lengths (i.e. no more than sleep in order to work safely and be fit for
14hrs length/10hrs break) and provide the work. Additionally the JMO has a duty to alert
opportunity for the JMO to obtain sufficient their employer if they have not had sufficient
sleep. sleep.

Attitudes and behaviours underpin all successful change strategies; without them, change is unlikely
to be successful. The attitudes and behaviours required to sustainably support and deliver a safety
culture must be fully integrated into a “business as usual” model.

• Hours of work
• Time off
• Length and timing of shifts
• Number of shifts in a row
• Breaks within and between shifts
Organisational • Provision of sleep opportunities
Responsibility

Fatigue
Junior
Medical
Officer • Home situation
Responsibility • Lifestyle
• Physical health
• Sleep habits
• Additional employment

08
 Risks & Controls

Managing risks by identifying, assessing and

actioning threats should be part of everyday
activities throughout the health system. Like any Identify
other workplace safety hazard, fatigue must be
risk managed in a step-by-step process. Risk
management encompasses the identification,
assessment and action of hazards that pose
meaningful risk to the health and safety of
employees in the workplace.
Risk Assess
Review Management
Traditionally, fatigue has been managed using
only ‘hours of service’ as the single layer of
defence. However, this framework promotes the
implementation of a fatigue risk management
strategy that goes beyond prescriptive work
hours, and moves into contemporary practice.
Adding error protection processes and personal Action
fatigue management. As per Safe Work
Australia, the risks associated with fatigue can
be managed by following a systematic process:

Identify
Identify the factors that cause fatigue in the workplace

Assess
Assess the potential risk of injury from fatigue

Action
Action risks by implementing effective and practical control measures

Review
Review these control measures to ensure they are working as planned

09 Fatigue Risk Management Toolkit

 Fatigue Risk
Management Tools

Identify. Assess. Action.

010
Fatigue Risk Management Framework

Controls Incident Risk

Practical Actions & Tips
For consideration
Trajectory Assessment

No specific controls necessary except where

40 hour week - Day shifts Level 0 fatigue is indicated at Level 2

Does the roster provide sleep opportunity?

• Rostered shifts ≤ 14 hrs length and ≥10 hrs Have you assessed the following?
break between shifts (no split shifts) • Are the control measures effective – are the
• Roster ADOs (combine with rest days) JMOs working safe hours?
Proactive

Level 1 • How often is fatigue likely to occur?

• Even distribution of after-hours work &
minimal consecutive night shifts • Has the JMO had adequate and regular
• Provide JMOs with rosters 2 weeks in breaks to rest, eat & hydrate?
advance

Has the JMO been able to sleep?

Have you assessed the following?
99 Sleep ≥ 6hrs in the last 24hrs
• JMO sleep pattern
99 Sleep ≥ 12hrs in the last 48hrs
• JMO fatigue & sleep habits
• Has the JMO been awake for an extended
period? • Contributing factors i.e. family, new baby,
Level 2 2nd job, social life, health issue
• Are there adequate facilities for rest, sleep,
meal breaks if required? • Does the roster need reviewing? (level 1
controls)
• Consult with JMOs when designing rosters

Are there Fatigue related behaviours? Have you assessed the following?
• Encourage JMO self -reporting and use of • Fatigue identification ≥ 3 signs in 15 minutes
Fatigue identification checklist • Complete Fatigue risk assessment
• Encourage 30min rest break Level 3 • Review current roster for excessive hours
• Encourage supervision during clinical • Consider reallocation to non-clinical duties.
procedures • On call back up staff called in/utilised
• Offer taxi vouchers for safe journey home • Review & implement control measures for
• Provide health and well being advice level 1&2

Has there been a Fatigue related error?

• Analyse fatigue related errors & near miss
reports
Have you assessed the following?
Reactive

• Assess if the error was fatigue related

• Develop local error proofing strategies
E.g. Double checking, improve work • Assess the timing of procedural tasks
environment, re-scheduling procedural Level 4 • Assess the sleep pattern of the JMO
tasks, staff awareness
• Assess the roster pattern of the JMO
• Support reporting of fatigue related errors
• Implement control measures for levels 1-3
into IIMS
• Escalate to Clinical Director/DMS

Has there been a Fatigue related Have you assessed the following?
incident? • Assess if the incident was fatigue related
• Escalation to DMS/Exec On call • Assess timing of critical tasks
• Enter into IIMS - Investigation of incident
Level 5
• Assess the sleep pattern of the JMO
• Implement recommendations from any
Actual • Assess the roster pattern of the JMO
investigation
• Assess the personal factors of the JMO
• Facilitate Open Disclosure if required Incident
• Implement control measures for level 1-4
• Provide 2nd Victim Support / EAP/JMO
support line • Liaise with PSO & WHS to assess the
system and look for improvements

Adapted from: Centre for Sleep Research, University of South Australia, as cited in Queensland Health (2009)
 Fatigue Risk Management Toolkit

Identify - Fatigue
Adapted from: Fatigue Risk Management System for the Canadian Aviation Industry. McCulloch et al (2007)

Fatigue Identification Checklist

Physical tick Mental tick Emotional tick

Yawning Difficulty concentrating Quieter than usual

Heavy eyelids Lapses in attention Increased stress levels

Blurred vision Difficulty remembering Reduced motivation

Failure to communicate
Head drooping Lacking energy
important information

Anxiety and decreased

Feeling tired after sleep Risk taking behaviour
tolerance

Reduced performance Disorganisation Mood disturbances

Slower reaction times Emotional outbursts

Impaired hand eye

Irritability
coordination

Headache Irrational reactions

Micro-sleeps

Sub-Total = Sub-Total = Sub-Total =

Grand Total =

A JMO who presents with 3 or more symptoms within 15 minutes is likely to be experiencing fatigue
related impairment.

Progress to formal assessment where Scores are >3 for the JMO

JMO Manager Signature: Date:

012
 Fatigue Risk Management Toolkit

Assess - Fatigue
Adapted from: AMA National Code of Practice – Risk Assessment Guide (2016)

Fatigue - Risk Assessment Guide

Review the current 7 day roster (Monday to Sunday). Tick the boxes that apply to the JMO.

Low Risk Medium Risk High Risk

…… Worked < 50 hours …… Worked 50 to 70 hours …… Worked > 70 hours

…… Shift length < 10 hours …… Shift length < 14 hours …… Shift length > 14 hours

…… No rostered overtime …… > 10 hours overtime …… > 20 hours overtime

…… Took three or more 10min …… Took one or two 10min …… No short breaks taken
breaks during shift breaks during shift during shift

…… Rostered on-call
…… Rostered on-call < 3 days …… Rostered on-call ≥ 3 days
continuously > 7 days

…… No night shifts …… At least 2 night shifts …… At least 3 night shifts

…… > 10 hour break between …… > 10 hour break between …… < 10 hour break on at least
shifts and 2 days off shifts and 1 day off two shifts. No days off

…… Forward shift rotation and …… Forward shift rotation but …… No stable direction or speed
predictable cycle changed cycle of rotation

…… Unpredictable roster
…… No changes to roster …… Some changes to roster –
multiple call-backs &
without notice overtime or call-backs
overtime
…… Sleep opportunity < 1 out
…… Sleep opportunity – 2 out
…… Sleep opportunity - 2 full of 2 sleep times at night, no
of 3 sleep times at night
nights of sleep opportunity for full night
including 1 full night of sleep
sleep

Risk Assessment Results – This provides a crude risk assessment only

Now review the roster over 14 days and then 28 days.

If Medium and High risks are still present, then this doubles the risk.

JMO Manager Signature: Date:

013 Fatigue Risk Management Toolkit

 Fatigue Risk Management Toolkit

Action - Fatigue
Adapted from: Fatigue Management Policy , Department of Health and Human Services, Ambulance Tasmania (2010)

Risk Suggested Fatigue Control Measures (tick as appropriate)

Minor increase in likelihood of fatigue

…… Undertake a risk assessment & implement rostering controls
…… Notify Clinical Supervisor/DPET/Clinical Director
Low
…… Team monitoring by peers
…… JMO self-management controls, e.g. self-monitoring of non-work hours, caffeine,
task rotation, self-paced workload, food and hydration

Moderate increase in likelihood of fatigue

…… Undertake environmental risk assessment & implement rostering controls
…… Notify Service Manager & Clinical Supervisor
Medium
…… Team and process management controls
e.g. increased supervision, task re-assignment, supervisory checks by bed
manager, buddy with a peer
…… Support additional rest breaks & taxi vouchers home

Significant increase in likelihood of fatigue

…… Undertake risk assessment – JMO must not start shift until fit for work
…… Modify the roster to enable immediate rest/nap
High …… Adjust the workforce to cover the shift & provide additional sleep hours
…… Notify Service Manager, Clinical Supervisor & Exec on call
…… File a fatigue report to Clinical Director & Director of Medical Services
…… Document the incident into IIMS as a corporate risk – loss of service

JMO Manager Action Plan:

Fatigue risk controls can be tailored to the organisation or to the individual sites based on current local processes.

JMO Manager Signature: Date:

014
015 Fatigue Risk Management Toolkit
Fatigue Risk
Management
Workbook
Identify. Assess. Action.

016
 Be aware of high-risk times for fatigue
• Midnight to 6 a.m. (especially 3 a.m. to 5 a.m.)
• The beginning and end of shift when handover occurs
• Working a shift without a break for a number of hours
• Early shift starts (before 6 a.m.)

017 Fatigue Risk Management Toolkit

 Fatigue Risk Management
Case Studies

The “Fatigue Risk Management Framework”

illustrated on page 11, is a model that provides
various levels of control within the system along
the incident trajectory in order to reduce and
minimise the likelihood that a fatigue related
incident will occur.

Understanding the Fatigue

Risk Management Framework
In order to understand the risk management framework,
fatigue that is related to an incident (level 5) is preceded
by a fatigue related error or near-miss (level 4), which
could have been anticipated by the recognition of
fatigue related signs and symptoms (level 3). These symptoms or behaviours can indicate that a JMO
has been unable to get adequate amounts of quality sleep, or has been awake for a long period of time
(level 2). Lastly, the JMO has been awake too long or not had sufficient sleep because the roster has
not allowed enough time between shifts or too many hours have been worked (level 1). If a JMO is only
working Monday to Friday 9am-5pm with no afterhours duties, this would be classified as the lowest
risk (level 0). The “Fatigue Risk Management Framework” addresses the 5 major levels of control by
designing defensive systems around each one.

Level 0 No controls necessary

Level 1 Organisational: ensure the roster gives JMOs the opportunity to get adequate sleep.

Level 2 Individual: ensure the JMO uses their time away from work to get adequate sleep.

Level 3 Behavioural: monitor the JMO for signs and symptoms indicating fatigue.

Level 4 Error: implement formal or informal fatigue proofing strategies to avoid errors / incidents.

Level 5 Incident: investigate whether fatigue was an issue in workplace errors / incidents.

018
 Level 1 - Opportunity to Sleep

Level 1 controls are designed to ensure that the work time arrangements or rosters give JMOs
adequate opportunity to get the sleep they need in between shifts. Ensuring they are not awake for
excessive lengths of time (because of work) in order to present, alert and fit for their shift.

Assessing and controlling roster risks is the responsibility of the organisation, namely the JMO
Manager or roster creator, under the supervision of the local Director of Medical Services (DMS) or
equivalent.

Several factors should be considered, such as:

• Maximum shift length of 14 hours
• Minimum 10 hour break between shifts
• Number of consecutive shifts worked (ideally a maximum of 11 days or four nights)
• Number of rest days rostered between shifts
• Forward rotating roster patterns

We also know that JMOs need time to participate and manage carer’s responsibilities, and need time
to relax and socialise. This should be factored into a roster / work schedule. Balance is required to
ensure that the rigid application of level 1 controls do not negatively impact on medical training or
workforce retention.

Level 1 - Case Study: The Roster

A concerned JMO called Ben, approaches the JMO Manager of a
medium size regional facility to complain about the roster submitted
to them a week prior to the commencement of their upcoming
rotational PGY 2 medical term. Ben is concerned because the roster
shows them working their usual Monday to Friday, starting with two
weeks of nights as RMO on duty for the hospital, interrupted by a
week of evenings with no rest days in between (effectively 21 days in
a row).

Ben feels this is unacceptable but the JMO Manager advises him
there has been a resignation in the local JMO workforce and they
have been unable to backfill them. Several other JMOs starting the
rotation have already had annual leave approved by the network co-
ordinator. Ben is concerned as he has never worked in this hospital
before and has just come off a week of nights from his preceding
rotation.

019 Fatigue Risk Management Toolkit

Work through the following 3 questions:

Can you identify at least 5 risks to fatigue in the case study?

1
2
3
4
5

Can you use the fatigue risk assessment tool to determine the likely level of risk?

Can you use the fatigue action plan to formulate an appropriate management plan?

Tools & Tips for JMO Managers

Try to get to know the following key documents:
Working Hours Award Table (Appendix 3)
• A resource for rostering from the mandated Medical Officers Award and Employment
Conditions.
HNE Health Roster Design Guidelines (Appendix 4)
• Useful tips for designing a safe roster.
AMA Code of Practice
• Look for points in the roster most at risk, extended shifts, on call and night shifts.
Monitor Shift Changes/Swap Form. (Rostering Best Practice)
• Monitor the fatigue implications of shift swaps or shift extensions with a shift swap form /
procedure.
Rostering Best Practice NSW Health
• www.health.nsw.gov.au/performance/rostering

020
 Level 2 - Getting Adequate Sleep

The purpose of level 2 controls is to identify JMOs who might not have been able to obtain
adequate sleep in the past 24-48 hours, either for non-work related reasons or because of un-
planned work; and to develop potential processes to assist JMOs who have had insufficient sleep.

These may include factors such as:

• Inadequate Sleep Opportunity - It could be that the roster was not adjusted properly using level 1
controls, or the controls were not effective and should be reviewed. (See page 11)

• Personal Stress - There might be events happening in the JMO’s personal life that affect their ability
to get adequate sleep (e.g. a sick child, social or family commitments, study or exams).

• Medical Issues – The trainee might be suffering from a cold, flu or a sleep disorder that is affecting
their sleep.

As individuals, JMOs have a responsibility to:

xx Use their time away from work appropriately to obtain adequate rest and recovery, and ensure
fitness for work.
xx Report any potential risks to their employer if experiencing fatigue related signs and symptoms.
xx Report any situation that might present a fatigue related risk.

Level 2 - Case Study: The Sleep Factor

A Registrar, David, is overheard in the doctors’ lounge speaking to
another clinician about his newborn baby and sick toddler at home,
which has contributed to less than 10hrs sleep over the past 2 days.
Prior to the shift David had managed to lose his keys at home and
arrived to morning handover late, visibly agitated. David is on call
this evening and has 2 evening shifts remaining. At handover, David
asks multiple times for patient information to be repeated and is
very short in his communication. Later in the day the consultant
recognises that David has been yawning during the ward round and
doesn’t seem as organised as usual during team interactions.

021 Fatigue Risk Management Toolkit

Work through the following 3 questions:

Can you use the fatigue identification tool to list the symptoms of fatigue in David?

Given the limited information, what do you think David’s fatigue score would be?

Can you use the fatigue action plan to formulate an appropriate management plan?

Tools & Tips for JMO Managers

AMA Fatigue Risk Assessment Tool - Allows a JMO to assess a 7 day period on their roster
(using the 7 days either side) to be independently risk assessed for fatigue.
http://www.safehours.ama.com.au/

Sleep Calculator - This site can optimise the length of your REM (deep, restorative) sleep. It
calculates either the best time to go to sleep (when you know when you need to wake up), or
the best time to wake up when going to sleep now. https://sleepcalculator.com

Sleep Hygiene Tips / Guide for Shift Workers

• Working the night shift – Royal College of Physicians booklet
• How to manage shift work – WorkCover NSW
• Fifteen minute consultation: problem in the health paediatrician - managing the effects of shift
work on your health – Dr Mike Farquhar

022
 Level 3 - Fatigue Signs & Symptoms

Level 3 controls involve the use of evidence based tools or individual indicators to identify if
someone is fatigued. The symptoms of fatigue indicate an increased risk of a fatigue related error
occurring. JMOs should monitor for symptoms in themselves and in others. A system of reporting
allows for appropriate action when the risk is high.

Signs and Symptoms of Fatigue

Where individuals or colleagues notice these signs or symptoms it could indicate an increased risk of
fatigue. These signs and symptoms could be:

• Physical – head nodding, rubbing eyes, lack of organisation, headache

• Mental – making errors, difficulty concentrating, short attention span

• Emotional – irritable, unmotivated, lethargic, quiet, withdrawn

It is critical that when these signs or symptoms have been noticed, they are reported up to a
supervisor, co-worker, manager or senior clinician. (See appendix 1 for more information).

Sleep Disorder Management

There are a number of conditions that can affect the ability to sleep and may cause fatigue. If a JMO is
experiencing prolonged bouts of fatigue or they have a suspected sleep disorder, it should be advised
that they make an appointment with their GP as soon as possible.

Level 3 - Case Study: Take a Break

A resident Mary, on one of the medical teams has been unwell on
her 2 ‘rest days’ post a run of 5 night shifts. She has found it difficult
to get back into a night time sleep pattern and has subsequently
had little sleep during her days off. On her first day shift back at
work, during the ward round she places the wrong patient label
into the notes of a patient. The registrar has picked up on the error
and corrected the mistake, however, the registrar suggests that the
resident might need to take a break.

023 Fatigue Risk Management Toolkit

Work through the following 2 questions:

What actions should Mary take to ensure that she is fit for work?

Use the fatigue action plan to formulate a management plan for Mary.

Tools and Tips for JMO Managers

• Practice using the fatigue risk assessment tool
• Monitor JMO behavioural symptoms, if you spot 3 symptoms within 15 minutes then escalate up
• Encourage JMOs to self-report fatigue to the JMO Manager or Clinical Supervisor
• Review effectiveness of your Level 1 & 2 controls – assess your rostering practices. Is there
room for improvement?
• Ask the JMOs for their feedback on the roster at a group forum or individually.
• Co-design the roster with a JMO representative.
• Stay up to date with rostering best practice – (Appendix 4)

024
 Level 4 - Fatigue Related Errors

Level 4 controls consist of formal or informal fatigue proofing strategies applied to reduce the risk
of an error or incident, where the risk of fatigue cannot be removed entirely. There are two clear
opportunities for the management of fatigue-related risk:

xx Reducing the likelihood of an error via appropriate rostering and fatigue countermeasures e.g.
napping procedures and error protection practices.

xx Reducing the consequences of fatigue-related errors by developing error tolerant systems that will
catch errors before they become a major incident.

Gathering and documenting locally tried and tested practices should form part of the level 4 controls.
These practices and strategies could be individual, team based, facility based or organisational. They
can also include non-technical skills such as communication, teamwork, leadership, and supervision.

Examples of fatigue proofing strategies

• Double checking systems
• Increased supervision or peer-to-peer monitoring
• Improving the work environment
• Using checklists
• Scheduling less critical tasks in the afterhours period
• Additional breaks and the promotion of napping
• Staff awareness and training on fatigue management
• Analysis of fatigue related errors and near miss reports with the patient safety officer
• Supporting individuals to report fatigue-related errors or near-misses via IIMS

Level 4 - Case Study:

Medication Near-miss
A medication near-miss was picked up by a nurse afterhours and
entered into IIMS. The next day the Nurse Unit Manager conducted
an investigation. It was discovered that the doctor who had made
the error had worked more than 240 hours that month. They
had worked many long shifts, some were 10 hours overnight and
some were 12 hour days. The doctor had been required to work a
number of night shifts at short notice to fill in for absent staff. The
JMO manager had not been able to recruit a locum due to budget
constraints. For the entire month, the doctor did not get two
consecutive days off in a row.

025 Fatigue Risk Management Toolkit

Work through the following 2 questions:

What risk factors potentially contributed to the doctor making an error?

What control measures could you put in place to prevent fatigue related errors after hours?

Tools & Tips for JMO Managers

Report Fatigue as a contributing factor in IIMS – (See Appendix 6 & 7)

Do you know what support services are available for JMOs?

It can be very stressful to be involved in an incident investigation, JMOs are often the 2nd
victims in these events and need to be supported through any enquiry. Let them know that
there is support available via:
• Employee Assistance Program
• JMO Support Line - 1300 JMO 321 or 1300 566 321
• Doctors Health Advisory Service (NSW and ACT) – 02 9437 6552
• Lifeline - 13 11 14
• Suicide Call Back Service - 1300 659 467
• beyondblue - 1300 22 4636
• SANE Australia Helpline - 1800 18 SANE (7263)
• Medical Benevolent Association of NSW
• JMO Health – are you ok?

026
 Level 5 - Fatigue Related Incidents

Level 5 controls consist of reporting fatigue-related errors and incidents including near misses,
for example a work related injury (e.g. needle stick) or a breach of policy or procedure. Following
an incident, an investigation should be completed in order to determine whether fatigue was a
contributing factor.

The investigation process should include the manager asking the following basic questions:
• Did the roster provide enough opportunity for sleep?
• Did the JMO involved in the incident actually get adequate sleep?
• Did anyone observe any symptoms related to fatigue?
• What time of day did the event take place?
• How long was the JMO awake immediately prior to the incident?

All fatigue related errors and incidents should be entered into IIMS and discussed at the hospital JMO
forum and/or General Clinical Trainee Committee (GCTC) meetings for education purposes and to
ensure appropriate review of the system.

Level 5 - Case Study: Prescribing Error

A JMO in Emergency has worked 8 evening shifts in a row, each
shift was 10hrs in length. It is now 9pm and the JMO has been asked
to chart the regular medications for Mrs Brown who is about to be
admitted and transferred to the ward.

In the middle of charting Mrs Brown’s medications the wardsman

arrives to take the patient upstairs. The JMO is rushed to chart
the medications on time to ensure that the complete notes can be
transferred with the patient as per hospital policy. At the same time
the ED registrar interrupts to ask the JMO what the management plan
is for Mr Smith who is waiting in Fast track. The JMO appears to be
stressed and struggling to cope with the acute workload.

After 24 hours on the ward, Mrs Brown experiences some chest

pain and goes into cardiac arrest and passes away. As this was an
unexpected death, the case is reviewed by the Patient Safety Officer.
It is discovered that Mrs Brown’s death was attributed to a heart
attack and that her usual heart medication had not been charted
or dispensed, despite being with her at the time of presentation to
the Emergency Department. It is likely that this prescribing error
contributed to the adverse outcome for the patient.

027 Fatigue Risk Management Toolkit

Work through the following 3 questions:

Identify the risk factors that may have contributed to the error and adverse patient outcome?
Who would you escalate the incident to?

How could you support the JMO through the investigation process?

How would you review and change the roster following this incident?

Tools & Tips for JMO Managers

• Remember to report fatigue as a contributing factor in IIMS – (See Appendix 7)

• Refer to the NSW Health Incident Management System for a flow diagram of the process –
(Appendix 6).

• Provide second victim support to JMOs

• Liaise with the Patient Safety Officer and the Work Health and Safety Officer to look for
ways to improve safety at your facility for both patients and JMOs.

028
 Education & Training

Education and training on the dangers of fatigue, the causes of sleepiness, the importance of sleep,
and proper sleep habits; are the keys to addressing fatigue in the workplace. Look to engage clinicians,
JMOs and service managers to build an effective safety culture. Education and training must cover a
broad number of domains that will promote job satisfaction, morale, and a respectful culture. This will
lead to improved workforce retention, and decreased sick leave rates.

Training opportunities Educational opportunities for JMOs:

for JMO Managers:
• JMO Handbook - Surviving Shiftwork and
• Fatigue Risk Management Education Toolkit Fatigue
• Annual Fatigue presentation / workshop • Fatigue presentation at hospital orientation
• Skill development: • Feedback on fatigue related errors & incidents
–– JMO Welfare – Improving health and - JMO Forum and/or GCTC
wellbeing • Resident Guide App – access to local rosters,
–– Rostering best practice and fatigue leave applications and allocations
reduction • JMO support lines
–– Understanding safety and human factors • My Health Learning Modules

Training opportunities for

Clinical Supervisors:
• Fatigue Risk Management Education Toolkit
• Annual Fatigue presentation / workshop
• Skill development:
–– Junior doctor mentoring and coaching
–– Giving effective feedback to doctors in
training
–– Managing a JMO in difficulty and
implementing a support plan
–– JMO Welfare – Improving health &
wellbeing
–– Medical Education and Clinical
supervision

029 Fatigue Risk Management Toolkit

Ongoing Review & Improvement

At a local level, managers need to regularly assess if there are any new and changing fatigue risks and/
or hazards, and that controls have been reviewed for continued suitability.

Organisational culture is key to providing an environment where JMOs feel safe and supported in
reporting personal fatigue and citing fatigue as a cause of errors and incidents for the purpose of
review and continuous improvement of the system and environment.

The Ministry of Health will continue to monitor and review “JMO Safe Working Hours”, with particular
attention to organisational compliance to the number of continuous night shifts that can be rostered
and the minimum rest breaks rostered following night shifts. Any future standards, employment
conditions and policies should be included in future revisions of this toolkit.

It is recommended that the Fatigue Risk Management Education Toolkit be reviewed every two years,
with the next review commencing in November 2020.

Identify
Look for opportunities
to improve

The
Plan
Review Continuous How can the system
Did the change work?
Improvement be improved

Cycle

Execute
Implement changes

030
031 Fatigue Risk Management Toolkit
Fatigue Risk
Management
Appendices
Identify. Assess. Action.

032
Appendix 1 - Signs & Symptoms of Fatigue

Physical Symptoms Mental Symptoms Emotional Symptoms

• Yawning • Difficulty concentrating on • More quiet than usual
• Heavy eyelids task • Withdrawn
• Blurred vision • Lapses in attention • Increased stress levels
• Head drooping • Difficulty remembering what • Reduced motivation
you are doing
• Feeling tired after sleep • Lacking energy
• Failure to communicate
• Reduced performance • Anxiety and decreased
important information
• Slower reaction time tolerance
• Risk taking behaviour
• Impaired hand eye • Mood disturbances
• Disorganisation
coordination • Emotional outbursts
• Lack of situational awareness
• Headache • Irritability
• Accidently doing the wrong
• Micro-sleeps • Irrational reactions
thing (error)
• Accidently not doing the
planned thing (omission)

The ‘3 in 15’ Rule

Those who present three or more symptoms in a short period of time (15 minutes) are likely to be
experiencing fatigue-related impairment.

(Adapted from Fatigue Risk Management System for the Canadian Aviation Industry. McCulloch et al, 2007)

033 Fatigue Risk Management Toolkit

Appendix 2 – Causes & Consequences of Fatigue

Factors that can cause, contribute to & increase the risks of fatigue

Work-related Factors Personal Factors

• Cumulative hours worked • Sleep quality and quantity
• Task demands (workload, time pressure) • Medical conditions
• Predictability of roster • Diet
• Type of work (physical/mental) • Alcohol and drugs
• Accommodation • Age and gender
• Time of day • Time of day that sleep occurs
• Commuting • Family and social life
• Recovery periods between shifts • General health
• Roster cycle length • Exercise
• Shift length • Lifestyle choices
• Payment incentives • Sleep disorders
• Environmental stressors (e.g. light, noise, • Environmental factors affecting sleep (noise,
climate, vibration) heat, light)
• Organisational culture • Secondary employment and voluntary work

The possible consequences of fatigue

Individual Employer Community / Patient

• Poor health and wellbeing • Increase in the frequency and • Increased potential for
• Impacts to cognitive consequences of fatigue- incidents to occur in the
functioning related incidents community (e.g. road
• Increased mortality rates crashes)
• Impacts to short-term
memory function • Increased costs associated • Increased need for trauma
with incident management counselling services
• Increased likelihood of social
alienation • Increased levels of • Increased use of medical
absenteeism and lost time facilities and allied health
• Increased instances of
services
relationship problems • Increased levels of
presenteeism (i.e. coming to • Broader ripple effects of
• Increased likelihood of being
work despite injury, illness or serious injury, disability and
involved in an incident
other, resulting in reduced death in the community
productivity
• Poorer workplace morale and
satisfaction
• Poor communication impacts
organisation image and
reputation (recruitment)

034
Appendix 3 – Working Hours Award Table

The following information has been drawn from the Public hospital medical officer’s award and
NSW Health employment arrangements:

Working Hours Award & Employment Arrangements

• JMOs should not exceed an average of 38 hours per week, by rostering 40

hours per 7 consecutive days or 80 hours per 14 consecutive days.
Ordinary Hours of • JMOs should be free from ordinary hours of duty for (not less than) two days
Work a week, or where this is not practicable, four days in each fortnight.
• Leave without pay (LWOP) can only be entered into a roster where a JMO
has formally applied for LWOP & application has been approved.

• Allocate JMOs 1x ADO per calendar month or every 19 shifts worked, and
must be factored into the released roster.

Additional Roster • JMOs can only accumulate up to 3 ADOs at any time.

Leave (ADOs) • ADO must be taken as whole days.
• ADOs accrued but not taken must be paid out (as overtime) at the end of
each term rotation.

• Where practicable, days off should be consecutive AND combined with

Rostered days off
other rostered time off.

Break between • Minimum 10 hours break between consecutive shifts.

consecutive shifts • Must have process in place to monitor compliance with this Standard

• JMOs must not be rostered shift periods totalling more than 14 consecutive
Maximum rostered hours (inclusive of meal breaks and handovers).
shift
• Must have process in place to monitor compliance with this Standard.

• Minimum rostered shift should be not less than four hours.

Minimum rostered • JMOs should not be rostered broken or split shifts. i.e. roster a shortened
shift day shift and start a night shift within the same 24 hour period (withstanding
an emergent on call obligations).

• All shifts over five hours must include a 30 min meal break.
• Day shifts, Monday to Friday – JMOs MUST have a minimum 30 minute
(unpaid) break from duty for the purpose of taking a meal.
Meal Breaks • Day shifts, Monday to Friday – If JMOs are required to work through their
meal break they shall be paid for the time worked.
• All after hours shifts are regarded as working, paid time and JMOs must
remain on the premises.

035 Fatigue Risk Management Toolkit

Appendix 3 – Working Hours Award Table

Working Hours Award & Employment Arrangements

• JMOs recalled for duty shall be paid a minimum of 4 hours at the

appropriate overtime rate.
• The employer must have a process to formally release the officer from recall
duty.
• JMOs NOT formally released who are then recalled again, within the first 4
On Call hour period, are NOT entitled to any additional payment until the expiration
of the 4 hour period.
• JMOs formally released who are then recalled again, within the first 4 hour
period, ARE entitled to another 4 hour minimum payment.
• Remote clinical appraisal by telephone is paid at a minimum of one hour.
• Frequency of ‘On Call’ rosters should not exceed one in three.

• Employers must not change the rostered hours for a JMO in the 7 days
immediately following commencement of sick leave.
Sick Leave
• A medical certificate is required where an absence exceeds 2 consecutive
days or where in employer’s opinion circumstances do not warrant one.

Roster Release • JMOs shall be given at least 2 weeks’ notice of rosters for ordinary hours,
Date and where practicable additional (overtime) rostered hours.

036
Appendix 4 – HNE Health Roster Design Guidelines

The following district guidelines should be applied to local roster design:

ROSTER DESIGN GUIDELINES

Forward Shift • Shift allocation must follow a forward shift rotation pattern. e.g. Days to
Rotation evenings to nights with a break before resuming days.
• All paid / unpaid meal breaks should be outlined on released roster i.e length
Meal Breaks / number per shift & how they should be ‘covered’ (Hospital at night team).
• Consider local.
• All ADOs should be incorporated into the released roster.
• ADOs should not form part of allocated rest days following evenings or night
Allocated Days Off shifts.
(ADOs) • Minimum of 2 ADOs rostered per 10 week term and 3 ADOs rostered per
11-13 week term. Additional ADOs rostered are dependent on balance and
rotational site manager approval.
• Where practical, JMOs rotating to another facility should not be rostered
night shift in the last 48 hours of their term, to enable adequate orientation at
Final Week of
next facility.
Rotation / Term
• Where this is not possible, site must communicate roster to next site as soon
as is practicable.
• Training Networks must provide sites with at least 4 weeks’ notice of JMO
allocations to enable adequate roster consultation and release.
Network Relief • Sites must not roster network relievers to any part of the final 24 hours
(Sunday) of their final relief week or final 48 hours if rotating to rural location
the following week.

• For PGY 1&2 - Maximum of 4 consecutive night shifts to be worked (10-12 hour
shifts) before 3 consecutive rest days break.
Maximum number • For PGY 3+ - Maximum of 7 consecutive night shifts to be worked (12 hour
of consecutive shifts) before 7 consecutive rest days break.
shifts • (Consideration for smaller / rural sites where staffing may not allow)
• Maximum of 11 consecutive rostered day shifts to be worked (8 hour shift)
before 2 consecutive rest days break.

• PGY 1&2 – Avoid more than 8 night shifts per 10/11 week term.
Night Shifts • PGY 3+ - Avoid more than 12 night shifts per 3 month term.
• (Consideration for smaller / rural sites where staffing levels may not allow)

• The roster should be entered into Health Roster at least 4 weeks prior to term
start date.
Health Roster
• Check Health Roster report for employee submitted roster disparities prior to
the end of each pay period.

037 Fatigue Risk Management Toolkit

Appendix 4 – HNE Health Roster Design Guidelines

• All JMOs are offered adequate opportunity to request at least 3 requests prior
Roster
to roster build.
Consultation &
• JMOs wishing to swaps shifts must complete a shift swap form & provide at
Swaps
least 24 business hours’ notice to allow swap to be risk assessed.

• Each site should record ‘Rostered Work Hours’ including rostered overtime,
on their original released roster.
• Each site should record ‘Actual Worked Hours’ including unrostered overtime
Recording
& on call hours, on an amended version of the original roster, at the end of
Rostered v Actual
each pay period.
Hours Worked
• Where JMOs, often Registrars & Advanced Trainees, are rostered to more
than one roster, roster creators communicate to ensure award & employment
conditions/standards are not breached.

• Roster sign off from one up / clinical supervisor or DMS prior to release.
Roster Creator • Should sign off as read & familiar with – Public Hospital MO Award,
Employment arrangements for MOs, AMA code of practice.

• Where possible, JMOs rostered ‘On Call’ should not be rostered overtime the
day before or day after being ‘On Call’.
On Call
• Where possible, adequate facilities should be provided to allow JMOs to stay
on site overnight, if required.

The above guidelines are drawn from the Public hospital medical officer’s award, NSW Health employment arrangements and the
AMA National Code of Practice.

038
Appendix 5 – AMA Risk Assessment Tool

Risk Assessment Guide - AMA National Code Another example would be where at least two
of Practice – Hours of Work, Shift Work and night shifts are worked in a week but breaks
Rostering for Hospital Doctors Aug 2016 are taken within shifts, the minimum break
between shifts is maintained and the shift cycle
The Guide is based on a 7-day cycle but as the
is predictable. In this case a potential high risk
hazards of shift work and extended hours are
is balanced by other measures and the overall
cumulative, this model should be applied to a
profile may be kept at the lower risk end of the
14-day period and a 28-day period as the items
scale.
in the higher risk column create a greater risk
the longer they are present. For example, if The purpose of scoring is to provide a crude but
less than half of any sleep is able to be taken simple way of highlighting risks to doctors, to
at night over a long period then the effects the hospital and to those dependent on both.
of sleep deprivation may be evident in work The profile can be adjusted to add specific risk
performance and individual health. factors relevant to the type of hospital, and
used to establish a preferred profile that meets
A simple scoring system may assist in assessing
patient and doctor needs as well as obligations
risks for doctors. Lower Risk Elements are worth
to provide and maintain a safe and healthy
1 point, Significant Risk 2 points and Higher
workplace.
Risk 3 points, and when a Significant or Higher
Risk Element is present for consecutive 7-day
periods the points should be doubled on a
rolling basis and then returned to normal points
when the cycle is broken.

For example, a doctor who worked more than

70 hours a week for 4 weeks would be scored
at 24 points in the final week. Conversely, if the
70-hour week was a one off then the score at
the end of the 4-week period would be between
6-9 points.

039 Fatigue Risk Management Toolkit

AMA Risk Assessment Guide (7 day period)

*Lower Risk * Significant Risk *Higher Risk

Less than 50 hours worked 50 to 70 hours worked More than 70 hours worked

No more than 10 consecutive Up to 14 consecutive hours in 14 or more consecutive hours

hours in any one period any one period worked at least twice

Scheduled shift plus part of A full shift cycle worked of at

Scheduled shift hours worked
next shift worked least 24 hours

Three or more short breaks One or two short breaks taken No short breaks taken during
taken during shift during shift shift

Little or no overtime More than 10 hours overtime More than 20 hours overtime

Rostered for on-call less than 3 Rostered for on-call duty 3 Rostered on-call continuously
days in 7 days days or more in a 7-day period for more than a 7-day period

No night shift or extended At least 2 night shifts or At least 3 night shifts or

hours into night shift extended hours into night shift extended hours into night shift

Less than minimum 10 hour

Minimum 10 hour breaks Minimum 10 hour breaks
break on at least two work
between work periods and 2 between work periods and 1
periods and no full day free of
days free of work day free of work
work

Forward shift rotation and Forward shift rotation but No stable direction or speed of
predictable cycle changed cycle rotation

Roster changed so much

No changes to roster without Changes to roster through
because of overtime and recalls
notice overtime and recalls worked
so as to be unpredictable
Less than half of sleep able
Maximum opportunity for sleep About two-thirds of sleep able
to be taken at night and no
to be taken at night including to be taken at night including
opportunity for one full night of
two full nights of sleep one full night of sleep
sleep

040
Appendix 6 – NSW Health Incident
Management System Process

Identifi cation of incident

Immediate action(s) to mitigate harmful consequences

Notifi cation of incident into the incident management system under relevant incident
type[s] & allocation of an initial SAC rating
Document the incident management system incident number in patient’s medical record

Prioritisation - Confirm SAC rating

Prepare and submit RIB for All SAC1 incidents and others as mandated by MOH

Investigation
Feedback and open disclosure - patient, family, staff, service

Clinical SAC1 Clinical SAC2 Clinical SAC3 & 4 Corporate SAC1 Corporate SAC2,
• Privileged RCA to • LHD investigation • Local • RCA (not 3&4
be completed submit report investigation/ privileged) or • Local
• Submit report within 45 days review at clinical other approved investigation as per
to MoH within 70 • Privileged RCA unit or division level investigation section 2, 3 & 6 and
days of the date if system issues • Aggregated • Submit report to Appendix A
of notifi cation suspected-RIB analysis as MoH within 70 days • Complete
into the incident required and RCA appropriate investigation in 45
management process/report as • Privileged RCA days
system per SAC1 if system issues • Trend aggregated
suspected-RIB data over time
required and RCA
process/report as
per SAC1

Classifi cation - confirm/apply final incident type[s]

Analysis - identification of emerging themes/trends contributing to incidents

Action - Implementation of recommendations +/- action plan

Taken from: NSW Health Incident Management Policy - PD2014 004 NSW Health Incident Management Policy

041 Fatigue Risk Management Toolkit

Appendix 7 – Reporting Fatigue as a Contributing Factor in IIMS

To enable HNE Health to capture meaningful data on fatigue related errors, near misses and incidents
it is vital that it is recorded as a contributing factor correctly in IIMS.

There are two notification forms that will most likely be used to for fatigue related incidents: Clinical &
Staff, Visitor, Contractor.

Clinical

This form should be used where fatigue was a contributing factor in causing harm to a patient or the
potential to cause harm e.g. medication error, wrong patient, wrong test etc.

After choosing the ‘Incident type(s)’ from the drop down, the ‘Contributing factors’ free text box will
appear. This is where you need to use the word ‘fatigue’. Add further information such as number of
hours worked at time of incident, your fatigue assessment score at the time of incident, number of
hours or continuous shifts worked prior to the incident etc.

Notifier designation is ‘Doctor/Medical Staff’

TIP

JMO Managers / DMS / WHS – Search for the ‘HNE JMO Fatigue Clinical’ report for your facility.
A de-identified monthly report should be discussed with the DMS and can be added to the
General Clinical Training Committees or local forums for educational purposes.

042
Appendix 7 – Reporting Fatigue as a Contributing Factor in IIMS

Staff, Visitor, Contractor

This form should be used when fatigue was a contributing factors in causing harm to a JMO or had the
potential to cause harm e.g. Needle stick injuries or a car accident on the way to or from work.

Below the Incident type(s) drop down, you will see the ‘Incident / Injury contributing factors’ box.
This is where you need to use the word ‘fatigue’. Add further information such as number of hours
worked at time of incident, your fatigue assessment score at the time of incident, number of hours or
continuous shifts worked prior to the incident etc.

Under the ‘person affected details section, use the free text box to list your Occupation as ‘JMO’. Staff
designation is ‘Doctor/Medical Staff’

TIP

JMO Managers / DMS / WHS – Search for the ‘HNE JMO Fatigue Report’ for your facility. A de-
identified monthly report should be discussed with the DMS and can be added to the General
Clinical Training Committees or local forums for educational purposes.

043 Fatigue Risk Management Toolkit

Appendix 8 – JMO Cab Charge Initiative

Information sent to all HNEL- This trial initiative will be in place for 12
months from 6th June 2018.
HD Acute Hospital sites – • All serial numbers must be recorded on the
June 2018 form upon receipt.

Junior Doctors (Interns to Advanced Trainees) • Vouchers can be used with any booked taxi
are at greater risk of fatigue related road traffic service 131 008 (or a kerbside pick-up).
accidents following extended overtime shifts, • Lost or stolen vouchers must be reported to
after hours shift patterns, increased working the Director of Medical Workforce as soon as
hours due to on call frequency or a reduction in possible so that they can be cancelled.
sleep obtained for non-work related issues.
• Requests for more vouchers should be
As part of the 2018 JMO Wellbeing Action Plan emailed to the Director of Medical Workforce.
and Fatigue Risk Management project, Medical • On the 10th of each month, the AHNM or
Workforce is trialling the provision of Taxi JMO Manager must email a copy of the
vouchers to the nine acute Hospital sites. These current form, accounting for all voucher
vouchers will be held by the After Hours Nurse serial numbers – used or unused – to Medical
Manager (AHNM) role, with some Medical Admin Workforce for auditing purposes.
support, and will be available to JMOs 24/7.
• Mater Mental Health JMOs should contact
All HNE Health employed junior doctors are CMN AHNM for vouchers at that Mater site.
entitled to request two (2) taxi vouchers
(including the return journey back to their car), if
they feel too fatigued or impaired to safely drive
home from their workplace.

Procedure:
1. The fatigued JMO calls the AHNM towards the end of their shift.
2. JMO requests two (2) Cab Charge vouchers (for home & back to car/next shift).
3. The AHNM records the date, time, shift, JMOs name, payroll number and department against
the correct voucher serial number on the form.
4. JMO can book a Taxi on 131 008 or via the app 13cabs at the end of their shift.
5. AHNM meets JMO to handover vouchers and check wellbeing.
6. Note: All JMOs require a 10 hour break between shifts – JMO Manager to notify relevant day
team, switch and Clinical Director if the JMO needs a later start time for their next rostered
shift.

N.B. This initiative does not extend to Locum travel requirements.

044
Other Resources / Support

NSW Health Policy Directives / Manuals

• Public Hospital Medical Officers (State) Award 2018 (Industrial Relations Commission of NSW)
PD2017_042 Employment Arrangements for Medical Officers in the NSW Public Health Service
• GL2007_023 Fatigue - Preventing & Managing Work Related Fatigue: Guidelines for the NSW Public
Health System
• PD2014_004 NSW Health Incident Management Policy
• PD2018_013 Work Health & Safety: Better Practice Procedures
• PD2015_049 NSW Health Code of Conduct
• PD2017_028 Rostering Best Practice PCP & Rostering Resource Manual
• NSW Health Rostering Capability Framework & Rostering Capability Matrix
• PD2015_043 Risk Management - Enterprise-Wide Risk Management Policy & Framework - NSW
Health

Australian Medical Association

• AMA National Code of Practice 2016
• AMA Safe Hours Audit 2016
• AMA Fatigue Risk Assessment Tool
• AMA Safe Handover, Safe Patients - Guide

Safe Work Australia

• Model Code of Practice: How to Manage Work Health and Safety Risks
• Guide for Managing the Risk of Fatigue at Work
• Fatigue Management – A Worker’s Guide
• Shiftwork - How to Devise an Effective Roster

Federal WHS Legislation

• Work Health & Safety Act 2011 No.137, 2011

045 Fatigue Risk Management Toolkit

References

• Australian Medical Association (2017) “Best Practice Rostering: Training and Resource Kit: Practical
Tools for Rostering Doctors”, Australian Medical Association Limited, [Online] Available from:
https://ama.com.au/

• Caldwell et al (2009) “Fatigue Countermeasures in Aviation” Aviation, Space, and Environmental

Medicine; Vol. 80, No. 1

• Cooper, M. D. (2000) “Towards a model of safety culture.” Safety Science, 36, p. 111-136.

• Dawson D. & McCulloch K. (2005) ”Managing fatigue: it’s about sleep” Sleep Medicine Reviews;
volume 9 Issue 5:365-80

• Ferguson, Sally & Neall, Annabelle & Dorrian, Jill (2013) “Strategies used by healthcare practitioners
to manage fatigue related risk: beyond work hours.” Medical Sociology Online. 7:24

• HETI (2014) “The JMO Census” HETI

• Horrocks, N. & Pounder, R. (2006) “Designing safer rotas for junior doctors in the 48 hour week”.
Royal College of Physicians, London, [Online] Available from: www.rcplondon.ac.uk

• Lerman SE et al (2012) “American College of Occupational and Environmental Medicine Presidential

Task Force on Fatigue Risk Management.” Journal of Occupational Environmental Medicine. February;
54(2):231-58.

• NSQHS “National Standards”, The Australian Commission on Safety and Quality in Health Care,
[Online] Available from: http://intranet.hne.health.nsw.gov.au/cg/clinical_gov_document_-_
intranet_only/fact_sheets/National_Standards_Fact_Sheet_-_CG_Web.pdf

• O’Keefe, K. & Gander, P. (2012) “Best practice rostering, shift work and hours of work for resident
doctors: A review”. New Zealand Resident Doctors’ Association (NZRDA), [Online] Available from:
www.nzrda.org.nz

• Reason, J. (1998) “Achieving a safe culture: theory and practice.” Work & Stress, 12(3), 293-306.

• Reason, J. (2000). “Beyond the limitations of safety systems”, Australian Safety News.

• Workcover NSW (2013) “Shift work: How devise an effective roster”, Workcover NSW, No. 225
[Online] Available from: www.workcover.nsw.gov.au

046
Acknowledgements

Dr MaryAnn Ferreux Dale Erwin

Project Lead Director of Medical Workforce
Director of Medical Services Hunter New England Health Service
Calvary Mater Newcastle

Dr Sergio Diaz Alvarez Victoria Wall

Clinical Director of Medicine Project Officer
The Maitland Hospital Hunter New England Health Service
Hunter New England Health Service

Dr Peter Finlayson Angela Lawrence

Director of Medical Services Acting JMO Manager
Rural & Regional Health services Calvary Mater Newcastle
Hunter New England Health Service

A/Prof Pooshan Navathe HRMOA President

Director of Medical Services Hunter Resident Medical Officer’s Association
The Maitland & Lower Hunter Hospitals Hunter New England
Hunter New England Health Service

Dr Laura Bird HETI Medical Training Network Project Funding

Clinical Superintendent
John Hunter Hospital
Hunter New England Health Service

047 Fatigue Risk Management Toolkit

Notes

048