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Effects of fatigue on surgeon performance and surgical outcomes: a systematic review


  • L. Sturm BSc (Hons); D. Dawson PhD; R. Vaughan MB BS; P. Hewett MB BS; A. G. Hill MD; J. C. Graham MB BS; G. J. Maddern MD.

  • Sources of support: The Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S) project is funded by the Australian Government Department of Health and Ageing and the South Australian Department of Health. The ASERNIP-S project receives no support by commercial sponsorship.

Professor Guy J. Maddern, ASERNIP-S, 199 Ward Street, North Adelaide, SA 5006, Australia. Email:


Background:  Sleep deprivation and disturbances in circadian rhythms generally lead to poor performance, but is there a link in surgery? This review aimed to determine whether fatigue has an impact on surgeon performance or surgical outcomes.

Methods:  Studies were identified by searching EMBASE, CINAHL, PubMed, The Cochrane Library, Current Contents and clinical trials databases. Inclusion of relevant studies was by application of a predetermined protocol and independent assessment by two reviewers. Each included study was critically appraised for its study quality according to the methods used for Cochrane Reviews. Data from included studies were extracted by one researcher using standardized data extraction tables developed a priori and checked by a second researcher.

Results:  From 823 potentially relevant studies, a total of 16 studies were included in this review: two randomized controlled trials, five non-randomized comparative studies and nine case series. Of five studies that directly measure clinical performance, three studies reported no significant difference as a result of sleep deprivation, while two studies found increases in complications or errors. Eleven studies assessed psychomotor skill performance using a variety of simulation-based methods when a participant was rested and/or fatigued. Two randomized controlled trials reported no significant differences, while the nine remaining studies reported mixed results. Surgical residents with less surgical training/experience appeared to be more affected than more senior residents.

Conclusion:  There is little evidence, as yet, to inform the issue of the effect of fatigue on surgical performance.

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