title: Effects of fatigue on surgeon performance and surgical outcomes: a  systematic review.
abstract: 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.
  
  
  CONCLUSIONS
  There is little evidence, as yet, to inform the issue of the effect of fatigue on surgical performance.
authors.affiliation: Australian Safety and Efficacy Register of New Interventional Procedures – Surgical, Royal Australasian College of Surgeons, Australia.
authors.forename: Lana
authors.initials: L
authors.lastname: Sturm
authors.forename: Drew
authors.initials: D
authors.lastname: Dawson
authors.forename: Richard
authors.initials: R
authors.lastname: Vaughan
authors.forename: Peter
authors.initials: P
authors.lastname: Hewett
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Hill
authors.forename: John C
authors.initials: JC
authors.lastname: Graham
authors.forename: Guy J
authors.initials: GJ
authors.lastname: Maddern
mesh_terms: D002983:Clinical Competence; D005221:Fatigue; D013502:General Surgery; D006801:Humans; D007396:Internship and Residency; D011597:Psychomotor Performance; D012892:Sleep Deprivation