Intended for healthcare professionals


Fatigue and risk: are train drivers safer than doctors?

BMJ 2017; 359 doi: (Published 13 November 2017) Cite this as: BMJ 2017;359:j5107
  1. Paul Greig, honorary senior clinical research fellow,
  2. Rosamund Snow, postdoctoral research assistant
  1. University of Oxford—Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX2 6HG, UK
  2. Correspondence to: paul.greig{at}

As evidence about the effects of fatigue grows, Paul Greig and Rosamund Snow argue that approaches from other industries where safety is critical should be translated into medical culture

Key messages

  • Fatigue is a major risk factor for mistakes and poor decision making in the workplace

  • Individual workers are very poor at assessing their own fatigue risk

  • Attitudes to breaks and long hours among healthcare workers would be considered unprofessional and illegal in other workplaces where safety is critical

  • No evidence shows that clinical workers are better able to withstand fatigue than those in other industries

  • You can assess and reduce your risk profile and support colleagues to do so

The working hours of clinicians spark much debate around the world, with regulators seeking to balance the risks of staff becoming fatigued against the need to maintain throughput and keep care costs down. A recent national survey of anaesthetic trainees found that fatigue continues to be a hazard,1 and the topic was debated this year in The BMJ.2

Good evidence shows that tired workers are more likely to make errors of judgment, react slowly, misinterpret data, omit key information, and fail to question things that are unsafe.345 Doctors have historically worked long hours, and in some countries shift lengths are still lightly regulated.6 European Working Time Regulations perhaps go the furthest towards managing fatigue risk, but they focus on individual shift length and averaged total working hours. Doctors can opt out of elements of the regulations, and the guidelines allow practitioners to discount certain kinds of work, such as training, private practice, and commuting time.7 Other industries where safety is critical place much more importance on the cumulative effects of fatigue, considering working patterns and careful management of breaks when assessing risk.

This places …

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