Nighttime Interruptions and Clinical Risk: A Systematized Review of After-hours Paging and Error-related Outcomes.

Abstract

Nighttime inpatient cross-cover combines fatigue, reduced staffing, limited patient familiarity, and frequent paging interruptions, with resident physicians carrying much of this workload in teaching hospitals. We conducted a systematized PubMed review (search executed January 2026; publications from January 2021 to January 2026) using a 4-concept search covering night or after-hours work, inpatient settings, interruptions (pages, alerts, secure messages), and medical errors or patient-safety outcomes. Each of 112 records was independently screened by all 5 reviewers against a priori eligibility criteria, with disagreements resolved by consensus. Of these, 45 were excluded at title/abstract and 48 at full text; 19 studies met the inclusion criteria. Designs were quality improvement [n=8 (42%)], interview or survey [n=6 (32%)], and observational or retrospective [n=5 (26%)]; most were academic teaching hospitals in North America. Overnight interruptions most often involved medication questions, plan-of-care clarifications, handoff-related communication, diagnostic workflow disruptions, or electronic alerts. Most outcomes were process measures or error surrogates rather than direct clinical endpoints. Interventions that standardized communication or restructured notification workflows consistently reduced interruption burden, improved handoff efficiency, or increased capture of clinically significant overnight events. Combined with fatigue, reduced staffing, and limited continuity, nighttime interruptions amplify cognitive load and increase vulnerability to delays, omissions, and unsafe cross-cover. The most consistent benefits came from structured handoffs, clearer escalation expectations, and strategies that reduce deferrable or ambiguous overnight communication. Multicenter studies linking paging events to downstream EHR actions and patient-centered outcomes are needed.