Healthcare & Nursing · United States

Healthcare cares around the clock. Who looks after its sleep?

Nurses and doctors work rotating 24/7 rosters, nights and extended shifts. Fatigue impairs attention and judgment, putting medication safety, clinical decisions and the drive home at risk.

See your workforce snapshot

Who this page covers

After-hours GP and home-visit doctors
Doctors in training (residents)
Forensic mental health hospitals (also see Corrections & Custodial Services)
Hospital pathology and imaging
Nursing agencies and locum pools (also see Professional Services)
Private hospitals
Psychiatric hospitals and inpatient mental health
Public hospitals

Reg Watch

What’s changed, and what’s coming

Regulatory change that affects how you manage fatigue in healthcare & nursing: what has changed in the last 12 months, and what is on the way.

Upcoming changeNo date set yet

Michigan Senate Bills 296 and 297, passed by the Senate on 15 April 2026, would bar mandatory nurse overtime and require 8 hours off after a 12-hour shift; they await the House. Pennsylvania's Patient Safety Act (HB 106) on nurse ratios remains before the Senate.

Regulatory changes checked as at October 1, 2026.

Regulation

Who regulates it, and what they expect

No federal law caps clinical work hours in a US hospital. What binds you is state law and accreditation. Sixteen states restrict mandatory overtime for nurses or for health care employees more broadly, each by a different mechanism, and California, Massachusetts and Oregon set nurse-to-patient ratios. Resident and fellow hours are set by ACGME accreditation standards that bind accredited programs and their sponsoring institutions, not attending physicians and not nurses. New York goes further and makes trainee hours a matter of state regulation for every Article 28 hospital.

Centers for Medicare & Medicaid Services — Regulated by

Who regulates it

State legislatures and health departments set the binding rules - California, Oregon, New York and Pennsylvania have the strongest. The federal Centers for Medicare and Medicaid Services sets the hospital Conditions of Participation, The Joint Commission accredits most hospitals for Medicare purposes, and the ACGME governs resident physician hours. OSHA, the ADA and the FMLA apply underneath all of it.

Your obligations

If you sponsor an accredited residency or fellowship, work must average no more than 80 hours a week over four weeks, scheduled clinical work periods must not exceed 24 continuous hours plus up to four for handover and teaching, and trainees must have one day in seven free and 14 hours free after 24 hours of in-house call. Eight hours off between work periods is an expectation, not a requirement. In New York the 80-hour average, the 24-hour ceiling and eight non-working hours between assignments are state regulation. Nurse overtime and ratio duties depend entirely on the state.

Consequences

State enforcement is direct. New York's labor department fines mandatory-overtime breaches, Pennsylvania's issues administrative fines, Oregon can impose civil penalties and act against a hospital license, and California ratio breaches draw health-department citations. New York hospitals also answer to the health department for trainee hour breaches under their Article 28 license. A program that breaches the work-hour standards risks ACGME citation or loss of accreditation, which ends it. Federal safety-duty exposure and workers' compensation apply to every fatigue-linked injury.

Penalties

New York: $1,000 first violation, $2,000 second within 12 months, $3,000 third or later, plus up to $500 for reporting breaches. Pennsylvania: $100 to $1,000 per violation. Oregon: civil penalties for conduct on or after 1 June 2025. OSHA general duty: $16,550 serious, $165,514 wilful or repeat (2025 levels, in force for 2026).

Sources: Cal. Code Regs. tit. 22 s70217 and IWC Wage Order 5; Oregon ORS 441.762-441.792, OAR 333-510-0130; NY Labor Law s167; Pennsylvania Act 102 of 2008; ACGME Common Program Requirements Section VI; Joint Commission National Performance Goal 12; 42 CFR 482.23; OSHA 2026 penalty schedule.

Fatigue-critical roles

Where fatigue matters most in healthcare & nursing

The roles where a fatigued worker is most likely to cause serious harm, the tasks that carry the risk, and why fatigue builds up in them.

Role	Risk	High-risk tasks	Why fatigue builds
Resident physician (PGY-1 intern, resident, fellow) Rules Regulatory designation Resident in an ACGME-accredited program (duty hours are accreditation standards, not law); in New York a 'postgraduate trainee' under 10 NYCRR 405.4(b)(6) (state regulation) Hours and rest ACGME CPR VI: 80 h/wk averaged over 4 wks, 24 h + 4 h transition, 1 day in 7 free. NY 405.4(b)(6): avg 80 h/wk over 4 wks, max 24 consecutive scheduled h, 8 h off between duties	Critical risk	Prescribing and dosing, procedures and admitting unwell patients alone overnight; handover after a night shift or 24 h on-call; driving home afterwards	Rotating nights, 12-14 h long days, 24 h on-call in some systems, quick returns; 60-80 h weeks in training posts
Registered nurse (RN), staff nurse; licensed practical/vocational nurse (LPN/LVN) Rules Regulatory designation None specific - general duty; state mandatory-overtime restrictions in about 16 states (e.g. NY Labor Law s 167; PA Act 102 of 2008) Hours and rest No federal cap. e.g. Or. OAR 333-510-0130: max 12 h in 24 and 48 h/wk, 10 h rest after a 12th hour; Cal. Wage Order 5 s 3: no required >12 h in 24 on 12 h AWS, 16 h hard limit	Critical risk	High-alert medicines (insulin, opioids, IV infusions) and double-checks at 03:00-05:00; observing deteriorating patients; patient handling; driving home after nights	12 h day/night rotations or rotating 8/10 h shifts, quick returns, mandatory or voluntary overtime, consecutive nights
Attending physician (anesthesiologist, surgeon, OB/GYN, hospitalist) Rules Regulatory designation None specific - general duty; attendings are outside ACGME duty-hour limits Hours and rest None - no duty-hour rule for attending physicians	Critical risk	Emergency surgery, anaesthesia and obstetric delivery at night after a full day list; next-day elective list after being called in; driving in at 03:00	Non-resident on-call 1:3 to 1:8, called in overnight, then a full day list next day; no rest rule after call-ins in most systems
Certified nursing assistant (CNA) / patient care technician (PCT) Rules Regulatory designation None specific - general duty; state mandatory-overtime laws reach CNAs in some states Hours and rest No federal hours cap for adults; FLSA prices overtime only	High risk	Two-person patient transfers and repositioning, overnight falls watch and 1:1 observation ('specialling'), vital-sign rounds and escalation, mobilising patients	Rotating or permanent nights, 12 h shifts, bank/agency shifts stacked on a primary job, 07:00 handovers
Clinical / staff pharmacist (overnight pharmacist) Rules Regulatory designation None specific - general duty (OSH Act s 5(a)(1); public employers only in State Plan states) Hours and rest No federal hours cap for adults; FLSA prices overtime only	High risk	Verifying and dispensing high-alert and paediatric doses overnight, aseptic compounding checks (chemotherapy, TPN), phone advice to wards while alone on-call	Resident nights in large hospitals or remote on-call after a day shift; lone overnight verification with no second checker
Medical laboratory scientist (MLS) / radiologic technologist (RT) Rules Regulatory designation None specific - general duty (OSH Act s 5(a)(1); public employers only in State Plan states) Hours and rest No federal hours cap for adults; FLSA prices overtime only	High risk	Cross-matching and issuing blood, phoning critical results, CT and X-ray imaging and contrast checks overnight; lone on-call after a day shift	Single-handed nights or call-ins after a full day, 24 h weekend on-call, broken sleep between call-ins

Stories

When fatigue made the record

Published findings and prosecutions from regulators, courts and investigators in the United States.

May 2021 · Washington, United States
Surgical resident with shift work sleep disorder oversleeps after 37 hours' work in two days and is dismissed; accommodation claim fails because he bypassed the disability office
- Legal
A second-year orthopaedic surgery resident at a state university in Washington, treated for shift work sleep disorder, had repeated lateness and later testified that sleep deprivation from the disorder caused it. On a trauma rotation at a teaching hospital he overslept and missed rounds after working 37 hours over the previous two days, six days after emailing his program director a first draft of proposed accommodations. The faculty competency committee, told he was failing the rotation even without that day, recommended non-renewal, and the Washington Court of Appeals upheld summary judgment for the university: the accommodation claim failed because he chose to bypass the university's disability services process, and the discrimination and retaliation claims failed because he could not show the performance reasons were a pretext.
Case US-healthcare-18Report an issue
Nov 2016 · Massachusetts, United States
On-call trauma surgeon falls asleep in his car; emergency surgery done without him
- Safety
- Legal
- Financial
While serving as the attending surgeon for trauma emergencies overnight at a city hospital, a senior spine surgeon left the operating room to eat in his parked car and fell asleep, missing an emergency operation that the chief resident then performed without the required attending surgeon present. The state medical board found he had breached hospital policy requiring the surgeon's presence during critical parts of an operation; he admitted falling asleep in his car. The case shows how falling asleep while on call can turn directly into a supervision failure in theatre.
Case US-healthcare-03Report an issue
Aug 2015 · Massachusetts, United States
Hospital front-desk worker moved to nights nods off on duty; Board awards benefits as role less safety-critical than a nurse's
- Legal
A hospital information coordinator in Massachusetts who helped visitors arriving at night was moved from a 7 a.m. to 3 p.m. shift to 11 p.m. to 7 a.m. in 2015. She sometimes nodded off on nights despite deep breathing, stretching and moving around, and was fired after video showed her asleep in her chair for several minutes. The Massachusetts Board of Review awarded benefits, finding nothing to show she fell asleep intentionally and distinguishing her job from a nurse monitoring life-sustaining equipment.
Case US-healthcare-17Report an issue
Mar 2013 · New York, United States
Night patient care associate with a day job nods off wrapped in a blanket beside high-risk elderly patients; benefits denied
- Legal
A patient care associate working 7 p.m. to 7:20 a.m. at a New York hospital was assigned to a cluster of four elderly patients at high risk of injury. At about 3 a.m. she was found motionless in a chair wrapped in a blanket and said she had nodded off, explaining that a day job made it hard to rest during the day. The Unemployment Insurance Appeal Board reversed an award of benefits, holding that in the totality of circumstances her actions were misconduct, and distinguished an earlier case where the employer knew of drowsy medication and overtime.
Case US-healthcare-16Report an issue
Oct 2012 · New York, United States
Night hospital switchboard operator sleeps through a doctor's four calls; benefits denied as cold and later sleep apnea claim do not excuse it
- Legal
A night-shift telephone operator at a New York hospital, whose duties included 'code' calls for patients in distress, had been suspended in 2011 for sleeping on duty on multiple occasions. One night in 2012 a doctor tried calling four times over 15 to 20 minutes while she was asleep, until a co-worker woke her, and she was fired. The Unemployment Insurance Appeal Board held that a cold did not excuse falling asleep, that her later claim of sleep apnea would not excuse it either, and that it was misconduct; benefits were denied.
Case US-healthcare-15Report an issue
Feb 2012 · Pennsylvania, United States
CT scan technician found asleep on night duty when a child is brought down for a scan; court enforces reinstatement without back pay
- Legal
A CT scan technician at a Pennsylvania hospital, already suspended within the previous year for sleeping on duty, was found asleep one night in 2012 when a child and his grandfather were brought to the imaging department for a scan, and the grandfather remarked that this might be why the scan had taken so long. The hospital fired her two days later, but an arbitrator ordered reinstatement without back pay because she had not been given the disciplinary interview the union contract required. The federal court rejected the hospital's argument that reinstating a technician who twice fell asleep on the job breached Pennsylvania public policy and enforced the award.
Case US-healthcare-14Report an issue
Aug 2009 · Ohio, United States
Hospital sued for firing worker with narcolepsy instead of moving her to a day shift
- Legal
After a long-serving hospital employee was diagnosed with narcolepsy, her doctors restricted her to day-shift work and she asked to be reassigned to vacant day positions she was qualified for. The hospital instead put her on medical leave and then dismissed her. The Equal Employment Opportunity Commission sued under the Americans with Disabilities Act, calling the refusal of a reasonable shift-change accommodation unlawful; the case was resolved in 2016. Shift reassignment is a recognized reasonable accommodation for sleep disorders.
Case US-healthcare-06Report an issue
Apr 2009 · New York, United States
Sleep clinic technician trainee on overnight 12-hour shifts falls asleep and logs nothing on a CPAP patient for 2 hours 16 minutes; benefits denied
- Legal
A sleep technician trainee at a cardiovascular practice's sleep clinic in New York, normally working three overnight 12-hour shifts a week, was assigned to monitor two patients, one undergoing a CPAP test, and had to log the patient's status every 15 to 20 minutes. He fell asleep and made no entries for 2 hours and 16 minutes, and was fired. The Unemployment Insurance Appeal Board rejected his claim that he only nodded off and held that sleeping by a health care worker responsible for patient safety was misconduct.
Case US-healthcare-20Report an issue
Feb 2009 · Massachusetts, United States
Overnight nurse monitoring a ventilator-dependent child falls asleep twice; appeals court rules dozing can be a knowing breach and denies benefits
- Legal
A licensed practical nurse placed by a nursing agency in Massachusetts worked 6:00 p.m. to 7:00 a.m. shifts monitoring a ventilator-dependent boy by closed-circuit television. She fell asleep on duty in 2008 and again in 2009, and was forced out. The unemployment agency awarded benefits, reasoning that falling asleep is inadvertent and that the boy's mother had condoned it. The Massachusetts Appeals Court reversed: given the life-sustaining nature of the post, the nurse had a duty to 'preempt or to combat fatigue or drowsiness' and had warning from the first episode, so her lapses were knowing violations of the employer's no-sleeping rule.
Case US-healthcare-13Report an issue
Jun 2007 · New York, United States
Home care nurse on two assignments who knew her medication made her drowsy falls asleep caring for disabled patient; benefits denied and overpayment charged
- Legal
- Financial
A staff nurse with a home care agency in New York, working a 40-hour 3 p.m. to 11 p.m. assignment plus an eight-hour shift one day a week, cared for a severely disabled young adult at the family home. Already warned after an earlier incident in 2007, she fell asleep on duty again later in 2007 and was removed from the assignment. The Unemployment Insurance Appeal Board held that staying awake was especially critical for a nurse caring for a severely disabled person, and that drowsiness from medication did not excuse her because she knew she was becoming drowsy and did not call for a replacement; benefits were denied and a $1,215 overpayment charged.
Case US-healthcare-12Report an issue
Jul 2006 · Wisconsin, United States
Nurse who slept at the hospital between back-to-back shifts gives wrong drug and patient dies; license suspended and hours capped
- Safety
- Legal
- Financial
A labor and delivery nurse at a hospital worked two consecutive 8-hour shifts ending at midnight, slept at the hospital, and began another 8-hour shift at 7:00 am. That day she infused an epidural medication intravenously instead of penicillin to a teenage patient, without scanning the barcodes or reading the label, and the patient could not be resuscitated. The state Board of Nursing suspended her license for nine months and, for two years afterwards, limited her to 12 hours in any 24 and 60 hours in any 7 days.
Case US-healthcare-05Report an issue
Jun 2003 · Missouri, United States
Nursing home nurse nods off and crashes after a double shift; 100 hours in 15 days
- Safety
- Legal
- Financial
A licensed practical nurse at a skilled nursing center left work at about 10.25 pm after a double shift, nodded off several times on the 22-mile drive home and crashed into a ditch, suffering serious injuries with more than US$85,000 in medical costs. She had worked about 100 hours over the previous 15 days, and a sleep medicine expert testified her schedule produced excessive exhaustion and uncontrollable sleepiness. The state appeals court accepted that she fell asleep at the wheel but upheld the denial of workers' compensation, finding drowsy driving home was a risk shared by the general public.
Case US-healthcare-02Report an issue
Mar 2002 · Wisconsin, United States
Nurse working 72-hour stretches across three employers falls asleep on duty; license capped at 60 hours a week with no nights
- Safety
- Legal
A registered nurse employed by a healthcare company and two other healthcare facilities frequently worked 72-hour stretches between her three employers without breaks. She fell asleep several times on duty, which the state Board of Nursing found exposed patients in her care to harm and neglect. The Board reprimanded her and limited her license to 60 hours a week and 16 hours a day, with no night shifts, no pool or home health work, and supervised practice.
Case US-healthcare-08Report an issue
Feb 2002 · New York, United States
Overnight private-duty nurse falls asleep beside a tracheotomy patient who cannot speak; firing upheld and arbitration award confirmed
- Legal
A part-time staff nurse at a New York hospital, also working there as a private duty nurse, was engaged for a midnight to 8 a.m. shift to supervise a patient recovering from neck surgery who had a tracheotomy and could communicate only by gesture or notes. The patient's family complained that she had fallen asleep and failed to respond to the patient's needs, and after investigating the hospital fired her for compromising patient care. An arbitrator found she had been sleeping and that the hospital had just cause, and the federal court confirmed the award and dismissed her challenge.
Case US-healthcare-11Report an issue
Jul 1997 · Illinois, United States
Intern falls asleep driving home after 34 hours on call; court rules hospital owed no duty to injured motorist
- Safety
- Legal
Two weeks into training, a first-year medical intern worked 34 hours of a scheduled 36-hour on-call shift, then fell asleep while driving home and crashed into a young woman's car, leaving her with a permanently disabling head injury. Her family sued the hospital, alleging it knew or should have known its intern was impaired by sleep deprivation from excessive hours. The state appeals court upheld dismissal of the claim against the hospital, finding no duty of care to non-patients under Illinois law, even though the state's hospital licensing law required compliance with resident duty-hour standards.
Case US-healthcare-04Report an issue
Aug 1995 · Kentucky, United States
Anesthesiologist reported asleep during four surgical procedures is fired; sleep apnea found after, court upholds dismissal
- Safety
- Legal
The director of anesthesiology at a hospital was reported by three doctors and a nurse to have slept during four surgical procedures, at times snoring. He was suspended and terminated; a sleep study a week later found severe chronic sleep deprivation from obstructive sleep apnea, which treatment then resolved. The federal appeals court upheld summary judgment for the hospital, holding that an employer may fire a person for conduct even if it is related to a disability, and that it is unsafe to employ an anesthesiologist who sleeps while performing his duties.
Case US-healthcare-07Report an issue
Jul 1995 · Alabama, United States
Night-shift nurse awake about 24 hours hits a roadside utility pole driving home; Alabama court sends the question of whether she fell asleep to a jury
- Safety
- Legal
A nurse driving home after a 12-hour night shift, awake for about 24 hours, left the road and hit a utility pole two miles from home. A state trooper said she told him she had become drowsy and fell asleep at the wheel; she later said she never felt drowsy. She sued the power company over the pole's placement and the trial court granted the company summary judgment, but the Alabama Court of Civil Appeals reversed on the negligence claim, holding that contributory negligence turned on whether she kept driving while drowsy, which was a factual question for a jury.
Case US-healthcare-19Report an issue
Feb 1995 · Alabama, United States
Respiratory technician on back-to-back 16-hour weekend shifts falls asleep driving home; no workers' compensation, but court lets her sue the hospital in negligence
- Safety
- Legal
A hospital respiratory technician in Alabama worked two 16-hour shifts every weekend with an 8-hour break between them. Driving home at the end of the second shift, at about 11:00 p.m., she fell asleep, crossed the median and overturned, suffering serious injuries. Two experts said the long shifts and short break raised her fatigue risk and that sleep deprivation was a factor. The Alabama Court of Civil Appeals held the crash was not 'in the course of' her employment, so workers' compensation was denied, but for that reason the compensation law did not bar her negligence claim, and it reversed the summary judgment for the hospital and sent the tort case back for trial.
Case US-healthcare-10Report an issue
Jul 1992 · New York, United States
Lone psychiatric nurse on 28 of 40 hours over a holiday weekend falls asleep driving home; compensation finding upheld as supported but sent back for explanation
- Safety
- Legal
A nurse on a children's psychiatric unit in New York stayed past her shift until 4:00 a.m. because her replacement called in sick, then returned for a regular shift and a required double shift ending at 8:00 a.m., working 28 of 40 hours as the only nurse on duty over a holiday weekend. Sleeping was not allowed in the building. Driving home, she fell asleep and hit a wooden pole, suffering serious facial and leg injuries. The Workers' Compensation Board found her falling asleep was 'a direct result of the unusually long hours'. The New York Appellate Division said the record supported that nexus, but withheld its decision and remitted the case so the Board could explain why it departed from an earlier contrary ruling.
Case US-healthcare-09Report an issue
Mar 1984 · New York, United States
Grand jury links teenage patient's death to 'long grueling hours' of unsupervised residents
- Safety
A patient died the morning after being admitted overnight to a city teaching hospital and treated by junior doctors. A county grand jury investigating the death concluded that the long, gruelling hours worked by unsupervised interns and residents led to her death; the two doctors on duty had each been working for about 18 hours when she was admitted. The grand jury recommended that the state limit consecutive working hours for interns and junior residents, and a state advisory committee went on to propose capping trainee shifts at 16 hours.
Case US-healthcare-01Report an issue

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How the suite fits

How each product connects to your obligations

Grades describe how strongly a product connects to an obligation. None discharges an obligation, and none carries a compliance warranty.

Sleepfit

Supports your general duty of care

Screening your nursing and medical workforce for undiagnosed sleep apnea, insomnia and distress supports your general safety duty. No US healthcare rule requires it, so it is a control you choose.

About Sleepfit

Fatiguefit4Duty

Supports your general duty of care

In an accredited residency or fellowship, a structured fatigue check at the point of work supports the requirement that faculty monitor trainees for signs of excessive fatigue. Elsewhere nothing requires it.

About Fatiguefit4Duty

Awareness eLearning

Supports your general duty of care

No US rule requires fatigue training for hospital staff; Joint Commission Sentinel Event Alert 48 advises it, and ACGME requires fatigue education in accredited residencies. Awareness eLearning supplies that content with a completion record.

About Awareness eLearning

Was It Fatigue?

Supports your general duty of care

No US rule requires fatigue to be examined after an adverse event; Joint Commission Sentinel Event Alert 48 advises it. Was It Fatigue? supports your event review with a structured analysis. A structured judgment aid, not a determination of cause.

About Was It Fatigue?

SleepWellBaby

Supporting new-parent staff through infant sleep is a retention and wellbeing measure for a shift-working workforce. No US healthcare regulation engages it, so it is a benefit, not a safety control.

About SleepWellBaby

Recommended bundle

Where we’d start in healthcare & nursing

Every bundle is priced on prevalence: your whole cohort gets access, and you pay for the share predicted to need each product. How pricing works.

Recommended · Levels 2 and 3

Prevention Bundle

Proactive fatigue risk: assess, manage and train, with sleep screening underneath.

Alternative · Levels 2, 3 and 5

Fatigue Lifecycle Bundle

Assess, manage, investigate: from the Census to the point of duty to the post-incident review.

Why this pairing in the United States

No US healthcare rule names a fatigue tool; Joint Commission Sentinel Event Alert 48 advises action, and ACGME requires fatigue education in residencies. Sleepfit screens, Awareness eLearning trains with a record, Fatiguefit4Duty supports trainee monitoring. Fatigue Lifecycle adds event review.

See what sleep and fatigue mean for your healthcare & nursing workforce.

Tell us roughly how many people you employ. Your snapshot models how many are likely sleeping poorly and what it costs, from published research for healthcare & nursing. Then choose who you’d cover, and we’ll take you to the right next step.

See your workforce snapshot

A sample workforce snapshot on a tablet: modeled sleep problems and the cost of poor sleep for 1,400 people in transport and logistics.

Healthcare cares around the clock. Who looks after its sleep?

Who this page covers

What’s changed, and what’s coming

Who regulates it, and what they expect

Who regulates it

Your obligations

Consequences

Penalties

Where fatigue matters most in healthcare & nursing

When fatigue made the record

Surgical resident with shift work sleep disorder oversleeps after 37 hours' work in two days and is dismissed; accommodation claim fails because he bypassed the disability office

How each product connects to your obligations

Sleepfit

Fatiguefit4Duty

Awareness eLearning

Was It Fatigue?

SleepWellBaby

Where we’d start in healthcare & nursing

Prevention Bundle

Fatigue Lifecycle Bundle

See what sleep and fatigue mean for your healthcare & nursing workforce.