Fatigue Risk Management System Resource Pack Published by the Queensland Government. The State of Queensland ISBN Copyright

Transcription

1 fatigue risk management system Resource Pack

2 Pubished by the Queensand Government. The State of Queensand ISBN Copyright protects this pubication. However the Queensand Government has no objection to this materia being reproduced with acknowedgement, except for commercia purposes. Permission to reproduce for commercia purposes shoud be sought from Queensand Heath GPO Box 48 BRISBANE Q 4001

3 Foreword Queensand Heath is presented with many chaenges in deivering heathcare services across the state, 24 hours a day, every day of the year. To meet the needs of patients at any time of the day or night, the doctors and other heathcare workers in Queensand Heath faciities often work ong hours throughout the night and on-ca over weekends, pubic hoidays and other times of need. This presents us with the chaenge of fatigue and its associated risks to staff and patients. To meet this chaenge, fatigue risk management must be incuded in our core business operations within Queensand Heath. I encourage a hospita faciities, departments and units to work through this Fatigue Risk Management System Resource Pack, to meet empoyer and empoyee responsibiities to manage fatigue risk. Effectivey managing fatigue wi improve safety, efficiency, productivity and operationa fexibiity for a invoved in our heathcare system. 1 Michae Reid Director-Genera Queensand Heath

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5 Contents Foreword...1 Executive summary...4 Acknowedgement...5 Fatigue Risk Management Systems (FRMS) Resource Pack...6 Section I Governance structures...15 Section II Conduct a fatigue risk scan...19 Section III Defences in Depth...25 Section IV Determine a training process...55 Section V Compete FRMS and impement Appendices Appendix 1 Deveopment of a change management pan...60 Appendix 2 Loca Working Group...62 Appendix 3 Fatigue risk register...64 Appendix 4 Data coection guide...67 Appendix 5 The scientific basis for risk threshods...71 Appendix 6 Fatigue countermeasures...77 Appendix 7 Fatigue Audit InterDyne (FAID)...80 Appendix 8 FRMS fatigue risk mitigation actions...81 Gossary References...88

6 Executive summary Fatigue is a common and unavoidabe by-product of the 24-hour deivery of patient care. Defined as a decreased capacity to perform menta or physica work, or the subjective state in which one can no onger perform a task, fatigue manifests in physioogica performance decreases and cognitive impairment. To this end, fatigue poses eevated risk to the staff and patients of Queensand Heath. Within the existing Occupationa Heath and Safety (OHS) egisative frameworks, fatigue is an identifiabe workpace hazard that must be managed in the same way as other hazards, ike chemicas and heavy machinery. Current egisation highights the need to provide a safe system of work, which ceary incudes effective management of fatigue-reated risk. 4 This supports faciities in incorporating the risk management of fatigue and fatigue-reated risks into core business operations. It is an important eement of Queensand Heath s systematic approach to managing the risks associated with fatigue. It wi resut in improvements to our work and workpaces, and meet Queensand Heath s duty of care to its staff and the pubic. As part of this initiative, Queensand Heath has reeased a Medica Fatigue Risk Management Poicy, which prescribes that a faciities must deveop a comprehensive Fatigue Risk Management System (FRMS). A FRMS integrates management practices, beiefs and procedures used to manage the risks of fatigue. It provides taiored defences against fatigue-reated risks through the use of objective threshods specificay for oca environments. This Resource Pack is based on scientific knowedge, best practice in other industries and information from Queensand Heath case study sites. The five major steps in the deveopment and impementation of a FRMS make up the sections of this Pack. Determining a governance structure for a faciity s FRMS is the initia step of the process. This invoves a range of individuas in the roes of District Chief Executive Officer, ine managers and supervisors, cinica directors and medica officers. Importanty, this incudes estabishment of a Fatigue Loca Working Group to oversee fatigue-reated risk in each faciity. A fatigue scan forms the foundation of the FRMS. This scan identifies acceptabe eves and specific incidents of fatigue-reated risks. Questions provided wi hep expore issues such as, where fatigue-reated risk is highest, and when, who and how it impacts the faciity. Pus, it considers current management of fatigue risks. The major day-to-day aspects of the FRMS are formed around the Defences in Depth framework. This is where most taioring occurs for oca conditions and soutions. The framework foows a five-eve incident trajectory with reated hazards and contros. The many practices, procedures, strategies and habits of faciities and departments wi ikey form a major part of the framework. Action tabe exampes are provided to document faciity threshods and corresponding contros to address fatigue-reated risk. The working time arrangements of rostered hours, actua hours, shift swaps and on-ca hours are discussed, aong with biomathematica modeing, actua seep and prior wake. Finay, an education program is an essentia part of the FRMS, either through a web-based education package or detaied instruction through workshops. Working through this Resource Pack wi assist you to deveop, design and impement a FRMS that is taiored to your specific working environment. It wi hep the deveopment of the FRMS document for your faciity.

7 Acknowedgement We woud ike to thank the University of South Austraia s Centre for Seep Research for their work in preparing this FRMS Resource Pack, particuary Dr Say Ferguson, Dr Matthew Thomas, Dr Sarah Jay and Professor Drew Dawson. The Queensand Heath project team for this FRMS Resource Pack incuded Susanne Le Boutiier, Chanta Casey, Terry Penrose and Sonia Swaow. We aso acknowedge the contributions of staff at the FRMS case study sites of Mount Isa, Cooktown, Mossman, Atherton, Townsvie, Mackay, Rockhampton, Redciffe, The Roya Brisbane and Women s Hospita, Princess Aexandra Hospita, Logan, God Coast, Stanthorpe and Mimerran. 5

8 Fatigue Risk Management Systems (FRMS) Resource Pack What s in this Resource Pack and how wi it hep us? Working through this Resource Pack wi assist you in deveoping, designing and impementing an FRMS that is taiored to your specific working environment. This Resource Pack has been designed on the basis of current scientific knowedge, current best practice in other industries, and most importanty for Queensand Heath, from information obtained and essons earned from 14 case study sites. It provides an overview of the FRMS deveopment process, incuding key steps to take and actions to foow. The major steps in the impementation of an FRMS are isted beow and each of these steps is the focus of a section in this package: 6 Define governance structure (Section I, page 18) Conduct a fatigue risk assessment (Section II, page 23) Design and document Defences in Depth strategies (Section III, page 28) Design a training process (Section IV, page 56) Compete FRMS document and impement (Section V, page 58). The Queensand Heath Medica Fatigue Risk Management Poicy defines the minimum requirements for the FRMS. Detais about the poicy can be found at

9 What are the steps in the impementation process? The fowchart beow outines the major steps that faciities need to progress through to impement, and continue to monitor, a taiored FRMS. Each of these steps are discussed in more detai through this pack A major component of successfu impementations that is not represented in this figure is the underying cuture into which an FRMS is introduced. Certainy, commitment from senior management, an active Loca Working Group and infuentia and prominent Loca Champions are important in promoting that cuture. However, promoting a workpace environment in which fatigue-reated risk is managed by a individuas is essentia. Appendix 1 has further information about encouraging a cuture in which the shared responsibiity of fatigue risk management can be successfu through the management of change. Major steps for FRMS impementation Commitment from senior management 7 Identity/recruit oca champion Convene oca working group Fatigue risk scan Data coection Identify current contro strategies Review current and identify potentia contro strategies Document arising from the FRMS (threshod breaches) shoud be under constant review with the data used to modify both threshods and contro strategies Document threshods and responses Fina Fatigue Risk Management Strategy document Consutation The ro-out of the FRMS may resut in modifications to threshods, responses and contro strategies Fatigue Risk Management Strategy in action FRMS shoud be under constant review, with an initia system review set for six months after initia impementation

10 What is fatigue? There are various definitions of fatigue, but for the purposes of this pack, fatigue can be defined as: A decreased capacity to perform menta or physica work, or the subjective state in which one can no onger perform a task. Fatigue manifests in physioogica performance decrements and cognitive impairment. Fatigue primariy arises as a resut of inadequate restorative seep, but is aso infuenced by time of day and prior wake. Thus, the critica factor impacting on fatigue eves is seep. This Resource Pack contains a detaied review of current iterature about seep deprivation, fatigue and performance changes that can impact safety (see Appendix 5). 8 Whose responsibiity is this? In short, it is everybody s responsibiity. Specific responsibiities wi be outined in detai in your FRMS but in a broad sense the responsibiity for managing fatigue-reated risk is shared between empoyer and empoyees. Fatigue is an identifiabe hazard that we know causes harm to individua doctors and their patients. There is a mora obigation, and under OHS egisation, a ega requirement to effectivey manage fatigue-reated risk. Can we put our hands on our hearts and say we are currenty doing everything reasonaby practicabe to manage the risk?

11 Occupationa Heath and Safety (OHS) framework A empoyers and empoyees have responsibiities under the Workpace Heath and Safety Act 1995 for maintaining safe workpaces. Under the Act and Reguations, once a risk is defined either through an incident or accident, or a risk assessment or hazard assessment, there is an obigation to manage that risk. The management of fatigue-reated risk is a shared responsibiity between empoyee and empoyer. Medica Fatigue Risk Management Poicy Queensand Heath has reeased a poicy that provides a framework for the deveopment and impementation of a fatigue risk management system (FRMS). The purpose of the poicy is to reduce errors and incidents in which fatigue is a contributory factor. The poicy currenty resides with HR and wi be administered through the Medica Advisory Pane. 9 The mora obigation At the end of a ong day shift a surgica registrar was asked to stay at the hospita to perform an emergency appendectomy. Due to deays in theatre avaiabiity the procedure didn t commence unti after midnight. Compications during the procedure ed the registrar to ring the senior consutant who was on-ca overnight. The consutant who was aso the unit director attended and assisted in competion of the case by 3:00am. On eaving the theatre the senior consutant observed the registrar was dispaying signs of extreme tiredness but suggested the registrar remain on site to dea with any compications in recovery. The registrar eventuay eft the hospita at 4:30am and was kied when her car ran off the road and coided with a stobie poe ony five minutes from her house. The crash investigation determined she had faen aseep at the whee. The coroner determined that the faiure of the senior consutant to act on the obvious signs of fatigue being dispayed by the registrar contributed significanty to the death.

12 10 Is fatigue something we reay need to consider? In a 24-hour operation, increased fatigue eves are unavoidabe. By definition, fatiguereated risk is eevated at night due to circadian factors, and increases with onger time awake (extended work hours). Thus, in Queensand Heath faciities in which doctors are required to work ong hours and/or night hours or on-ca, fatigue-reated risk exists. In 2000 a pariamentary inquiry into fatigue in the transport sector determined that fatigue is a workpace hazard that must be managed in the same way as other hazards, ike chemicas or manua handing. Whie the recommendations of that inquiry were specific to the transport sector, changes are occurring in other sectors and in OHS egisation. These changes wi see the management fatigue associated with working time arrangements (or a system of work) soon become mandatory across the majority of workpaces. Queensand Heath has reeased a Medica Fatigue Risk Management Poicy to which a faciities must adhere in the given timeframe. Risk management of fatigue and fatigue-reated risks must be incorporated into Queensand Heath s core business operations. In order to faciitate this, Queensand Heath has endorsed a systematic approach to managing the risks associated with fatigue. This systematic approach to fatigue risk management wi improve safety, efficiency, productivity, operationa fexibiity and Queensand Heath s duty of care to its staff and the pubic. Fatigue risk management the Queensand Heath context In the twentieth hour of a 24-hour shift a fatigued doctor assessed a chid who ater died of head injuries. The case is the subject of a coronia inquest and Queensand Heath is being required to expain the systems that have subsequenty been put in pace to manage fatiguereated risk in its hospitas and risk to both doctor and patient safety. There were significant ramifications for a parties invoved in the incident.

13 What is an FRMS? An FRMS is an integrated set of management practices, beiefs and procedures for monitoring and managing the risks posed to heath and safety by fatigue. It is based in safety management system theory with an emphasis on risk management. Broady, an FRMS incorporates: FRMS document The FRMS document defines and detais the way that fatigue-reated risk is deat with in the organisation and is essentiay the written version of the FRMS. The FRMS document wi be simiar to some of your hospita s other human resources and OHS documents in that it directs responses to a specific risk. Risk mitigation strategies Defences in Depth framework (see figure beow), this forms the major practica or day-to-day aspect of the FRMS and incudes toos, strategies and contro measures for monitoring and managing fatigue-reated risk. Education program A empoyees need to be made aware of the risks posed by fatigue in the organisation, and the individua and organisationa strategies that are empoyed in managing that risk. Audit function The system must be monitored for continuous improvement and to ensure it is fexibe to change with changing work practices or functions. The audit function is essentiay buit into the Defences in Depth framework. 11 Hazard assessment Contro mechanism Incident trajectory Adequate seep opportunity? Leve 1 Hours of work guideines Proactive Acceptabe eves of prior seep and wake? Leve 2 Individua fatigue ikeihood score Prior seep/awake assessment Are there fatigue-reated behaviours? Leve 3 Subjective reports Individua/coegia symptom checkist Reactive Fatigue-reated errors? Fatigue-reated incidents? Leve 4 Leve 5 Anaysis of fatigue-reated errors and near miss reports Incident anaysis Address eves 1 4 Source: Centre for Seep Research, University of South Austraia Defences in Depth framework The Defences in Depth framework is discussed in more detai in Section III. Briefy however, the framework provides mutipe ayers of defence against the occurrence of a fatigue-reated incident. It s not ony about work hours.

14 12 Why use an FRMS? In the past, fatigue management has primariy invoved prescriptive rues about working hours. Within such a framework there is an inherent assumption that if you foow the rues you wi be safe. This is ceary not aways the case. For exampe, there are many reasons why an individua may not achieve adequate seep. They may choose to sacrifice seep for other activities such as famiy, socia, eisure, etc. Aternativey, seep may be disturbed because of iness (of sef or others), noise, temperature, etc. Thus, athough an adequate opportunity is provided by the working time arrangement, there is no guarantee that seep wi be obtained, and importanty, no capacity in the system to detect or act on inadequate seep. Further, situations occur when seep may have been obtained in the seep opportunity, but due to time of day, or workoad for exampe, fatigue-reated behaviours can occur. At 3:00am fatigue eves are naturay higher due to circadian infuences. If work hours are the ony risk mitigation strategy there is no capacity in the system to detect other precursor events or signs that a fatigue-reated incident may occur. An FRMS provides severa ayers of defence against fatigue-reated risk. A risk management approach provides for taioring of an FRMS in an industry in which a one-size-fits-a soution is not viabe. Queensand Heath is one of the most decentraised heath services in Austraia, requiring fexibiity rather than prescription. On a daiy basis, doctors are performing risk assessments with regard to their cinica decisions. It is ikey that doctors aso make judgements about their abiity to perform a task, taking into account their current eve of impairment (if any), the consequences of not acting, and the ikeihood of something going wrong. These decisions wi be supported by an FRMS through the use of objective threshods that wi be determined based on the oca environment. For further reading see Dawson and McCuoch (2005) isted in the References section (page 88). 1 FRMS phiosophy reative risk in heathcare settings An FRMS acknowedges that fatigue management in heathcare is not as simpe as working fewer hours, or just decaring yoursef not fit for duty when you have worked in excess of a set threshod. One key phiosophy of an FRMS has been articuated as: The risk of withdrawing a medica-reated service must not exceed the risk of a fatigue-reated error occurring. One of the more controversia arguments made is that sometimes a tired doctor may be better than no doctor at a. This is trying to convey the concept of reative risk. For instance, the risk of not providing care to a patient requiring an emergency caesarean at 4:00am in the morning might we outweigh the risk of making a fatigue-reated error. Much can be done to tacticay manage fatigue. Tactica fatigue risk management requires deveoping a fexibe work system that can respond to instances of fatigue when they arise on a day-to-day basis. Thus, whie much of the FRMS is designed to reduce the ikeihood of fatigue occurring, other components of the FRMS focus on minimising the risk when fatigue does occur. Fatigue must be seen as a natura part of the human condition, and as such can never be competey eiminated. A we designed FRMS wi reduce the occurrence of fatigue and effectivey manage fatigue risk when it occurs.

15 Work : a weekend away from work Wake : <2h prior wakefuness Seep : 4.3h seep in prior 24h Activity Leve Seep Duty This figure iustrates seep/wake data coected by an individua doctor at one of the case study sites. The roster provided a weekend away from work. Using work hours as the ony measure (Leve 1 contro in the Defences in Depth framework), fatigue-reated risk woud be deemed acceptabe and no risk mitigation contros woud be actioned. However, an assessment of the actua seep obtained (Leve 2 contro the Defences in Depth framework) demonstrates that the amount of seep that the doctor obtained in the 24-hour period prior to work beginning was ess than five hours. Five hours of seep is associated with increased risk of impairment. Without an assessment of risk associated with actua seep, the inadequate seep woud not be detected and contros woud not be actioned. 13 Work : 13.5h break between shifts Wake : 4.5h prior wakefuness Seep : 4.6h seep in prior 24h Activity Leve Seep Duty This figure iustrates seep/wake data coected by an individua doctor at one of the case study sites. The roster provided a 13.5-hour seep opportunity in between work periods. Using Leve 1 assessment and contros ony (work hours) fatigue-reated risk woud be deemed acceptabe and no risk mitigation contros woud be actioned. However, a Leve 2 assessment demonstrates that the amount of actua seep obtained in the 24-hour period prior to work beginning was ess than five hours. Five hours of seep is associated with increased risk of impairment. Without an assessment of risk at Leve 2, the inadequate seep woud not be detected and contros woud not be actioned.

16 What is this reay going to take? There are some key factors that are critica to the successfu deveopment and impementation of a taiored FRMS. These are: senior management commitment and support a Loca Working Group (LWG) with representation from a departments/divisions oca champions project officers in support of the LWG/departments/divisions district eve content experts. The work done with the case study sites demonstrated very ceary that having these components in pace maximises the productive use of time of aready busy medica officers whose input is essentia throughout the whoe process. 14 The LWG, supported by the Executive Director of Medica Services (EDMS) or Director of Medica Services (DMS), oversees the impementation process and subsequenty wi review FRMS reports and direct and support resutant actions. Together with the LWG, the Loca Champions roe is to inform and advise peope about the FRMS, and encourage the necessary changes required to move towards a cuture of fatigue risk management by a parties. Project officers or administrative support is important in puing together the document, but in most cases this needs to be done in conjunction with other Loca Champions or cinica directors (or proxies). From the outset, it is important that the organisation create and foster a cuture in which it is OK for a doctor to put up their hand and say I haven t had enough seep to do this safey or, I am having troube concentrating on this task. There are countess arguments against the impementation of fatigue management strategies and none of them justify a ack of action on patient or occupationa heath and safety grounds. Some common ones are isted in the foowing breakout box. The common excuses for not taking action on fatigue risk management A of these statements have arisen during one or more conversations during the Aert Doctors Strategy FRMS project. Whist many of these highight egitimate issues, none warrant inaction. The trainees won t get enough exposure to cases. Continuity of care wi be affected. I did it this way. There s no-one ese to do the work. You have to be abe to function under pressure incuding seep deprivation. I don t need much seep. We work shifts, there isn t a fatigue issue. This won t change anything. We don t know what they do away from here. When the conversations are taken further, none of these barriers is deemed to be reason enough to not take action to manage the day-to-day fatigue-reated risk in a faciity. A workshop conducted with Medica Superintendents additionay brought a range of site-specific issues to the fore, but again, a in the room were in agreement that these chaenges shoud not prevent action on the ground to safeguard doctor and patient heath and we-being. Many of the case study sites were sti abe to impement FRMS contros after taking these issues into consideration.

17 Section I Governance 15 structures

18 Roes and responsibiities An initia step in the process of impementing an FRMS is to determine the governance structure by which the FRMS wi be administered and to stipuate the key roes and responsibiities in your FRMS document. The Queensand Heath Medica Fatigue Risk Management Poicy (beow abbreviated to the Poicy) defines the responsibiities to various individuas. These incude the Director-Genera, Executive Management Team, District Chief Executive Officer/District Manager, EDMS or DMS, cinica directors of departments, the Fatigue Loca Working Group (LWG), and individua medica officers. Responsibiities are isted beow in brief but you shoud refer to the Poicy. 16 Director-Genera The Director-Genera wi support the impementation and maintenance of FRMS in Queensand Heath. The responsibiities of the Director-Genera in this capacity are to: Ensure the observance of the Poicy Advise government of barriers preventing extreme and major eve risks being managed to as ow as reasonaby practicabe Prioritise aocation of avaiabe resources to reduce high-risk fatigue to as ow as reasonaby practicabe (deegated to Deputy Director-Genera Poicy, Panning and Resourcing). District Chief Executive Officer Monitor district compiance with Poicy Ensure risk contro measures are appropriate for ongoing extreme and major eve risk situations in accordance with the Queensand Heath Integrated Risk Management Poicy Prioritise aocation/reaocation of resources to reduce extreme and major eve risk fatigue Advise Director-Genera of barriers preventing extreme and major eve risks being managed. Line Manager/Supervisor (EDMS, DMS, MSRPP, Cinica Director, most senior reevant cinician) Ensure FRMS meets a requirements of the Poicy Ensure compiance with FRMS by medica staff and reevant cinica staff under their supervision Respond appropriatey to reports of fatigue-reated incidents, errors or behaviours Ensure training for sef and direct reports required by FRMS is competed Where organisationa deegations permit, ensure avaiabe resources are aocated in a manner that reduces fatigue-reated risk to as ow as reasonaby practicabe Advise supervisor of barriers preventing extreme and major eve risks being managed. Medica Officers (individua doctors) Present at work in a fit state to conduct duties safey Compete a training required by FRMS Identify, report and respond to actua and potentia risks associated with fatigue according to the FRMS Inform the appropriate individua where adequate seep has not been obtained Decare any work hours outside of rostered work at primary pace of empoyment where it woud eevate the risk of fatigue above that which woud otherwise be expected.

19 Patient Safety, Workpace Heath and Safety and Shared Services aso have roes and responsibiities under the Poicy. An important component of your FRMS governance structure wi be the Fatigue Loca Working Group. Fatigue Loca Working Group (LWG) The LWG wi be the committee with responsibiity for overseeing the monitoring and management of fatigue-reated risk in the hospita. The LWG wi aso pay a vita roe in the creation and fostering of a cuture in which fatigue risk management is we received and adopted as the norm in the workpace. Within this brief the LWG wi: report directy to the EDMS iaise with patient safety committees or other OHS committees where they exist to ensure consistency between procedures design, taior and impement an FRMS ensure a reevant empoyees compete appropriate training in fatigue risk management continue to review, monitor and improve fatigue risk management practices in response to changing operationa needs and feedback. 17 Appendix 2 contains specific detais about the LWG, incuding Terms of Reference and exampes of typica meeting agendas. In smaer sites, a stand-aone LWG is often not required. Instead, fatigue risk management can be incuded as a standing item on the agenda of another reevant committee for exampe, the OHS or patient safety committee, or the management committee. There are a number of different ways to convene LWGs. Some exampes from the case study sites are provided beow. A medium sized hospita with some speciaity services had not formay discussed fatigue risk management issues prior to the case study process beginning. The DMS convened a Loca Working Group that incuded a project officer who was aso the patient safety officer, severa medica staff and administrative support. The LWG initiay met fortnighty but the frequency of the meetings was reduced to monthy as the workoad essened. The Loca Working Group initiay assessed panned and actua hours worked by medica officers and aso reviewed work practices as a starting point for their activities. A regiona faciity made the decision to incude fatigue risk management as a standing item on the agenda of the cinica governance committee. The committee incuded medica officers, aied heath and nursing staff, patient safety and OHS officers. A of the smaer sites that participated as case studies simpy added fatigue risk management to agendas of other reguar meetings. A major component of risk management in sma sites is the team aspect and thus nursing and aied heath staff are critica in the successfu impementation and action of the fatigue risk management system.

20 Key tasks: Governance structure These are the key tasks reating to the estabishment of an appropriate governance structure for your FRMS: Liaise with the District Chief Executive Officer/District Manager on district resources and project support. Estabish top-eve management commitment across the faciity. Identify a project officer and Loca Champions. Decide on the most appropriate format for your Loca Working Group. Convene the Loca Working Group. 18

21 Section II Conduct a 19 fatigue risk scan

22 What is our fatigue-reated risk? 20 As fatigue is a risk to be considered for any organisation providing round-the-cock service, the rea question pertains to the degree of risk that is acceptabe with reation to fatigue. In order to determine this, a number of questions need to be initiay addressed to determine current fatigue-reated risk. Where is our fatigue-reated risk highest? When does it impact? Who does it impact? How does it impact? A fatigue risk scan wi identify the specific occurrences of fatigue-reated risk in an individua unit or faciity. The fatigue risk scan requires a group of peope with current knowedge about the working environment. Other individuas that coud contribute to this process incude your OHS officer, a patient safety officer, and personne with risk management expertise. Specificay, the questions that shoud be addressed in some detai are: When is fatigue-reated risk increased for us? When in the roster or the day or the week or the year is risk increased? When fatigue-reated risk is increased, who is it impacting? Is there a specific group of doctors within the hospita/department that are at increased risk due to the nature of their work arrangements? How does the increased risk impact? What tasks are susceptibe to fatigue? How does performance change? Is the patient or doctor at risk or both? Other questions, based on the Defences in Depth framework, might incude: To inform our assessment, what information do we have about hours of work, actua seep, time awake, fatigue reports, etc? Do we need to coect some more information or data about these factors (see Appendix 5)? What is the information teing us? What do we need to do differenty (eg. work practices)? Can we do things differenty? What prevents/restricts us from changing things and are these reasonabe barriers?