Fatigue induced deterioration in cognition has significant implications for working practice within the National Health Service. Although attitudes are changing, few safety measures have been implemented to reduce fatigue related error. The World Health Organisation Operative Checklist is one error prevention strategy developed to address error preoperatively.
With rising negligence costs there is an argument for error rates persisting, if not increasing, despite the European Working Time Directive (EWTD). Although work hour limitations have attempted to be met by employers, the ability to take four hourly breaks is not easily manageable or regulated due to impingement by patient care. Requests by employers for staff to opt out of the EWTD have occurred due to the system being unable to function within the directive. Fatigue caused through variations in circadian rhythms is not accounted for by the EWTD.
Fatigue is a recognised cause of memory lapses, impaired communication and judgement. Individuals can experience emotional blunting, lapses in attention and experience difficulty in maintaining focus. Public complaints reflect the aspects of care that they see. The fatigue related breakdown in inter-personal skills is certainly a contributing factor.
Clinical information forms the basis for decisions on which we act. Inaccurate information, uncertainty in our recollection or inability to recall important facts can place patient safety at risk. This thesis investigates the impact of fatigue on the recall of clinical information in the non-sleep deprived state. Chapter 1 is the introduction and discusses the principles of the National Health Service (NHS) and why acute mental fatigue should be prevented, Chapter 2 introduces the concept of “memory” and the theories to its mechanism of action. It provides background on the approach to improving the recall of information. Chapter 3 is a systematic review of Acute Mental Fatigue in the non-sleep deprived state and highlights the impact of fatigue within healthcare organisations. Chapter 4 describes neuroenhancement and reviews the pharmacological agent Modafinil, discussing its possible applications for use in cognitive fatigue. Chapter 5 is a survey to provide background levels of fatigue in NHS doctors post EWTD. Chapter 6 is a randomised crossover study investigating recall of clinical information in the mentally fatigued, non-sleep deprived state. The subsequent Chapter 8 and 9 develop cognitive and pharmaceutical intervention strategies to improve recall of clinical information. Chapter 8 investigates the recall of clinical information after a working day in a randomised crossover study comparing a computerised handover checklist (using cognitive cues) to current handover methodology. Chapter 9 compares neuropharmacology to cognitive strategies of cue based recall to enhance recall of clinical information.
Finally, the discussion in Chapter 10 reflects on the strengths and weaknesses of these studies and possible implications for the clinical practice.