The impact of staff fatigue on patient safety

Summary of the investigation

The investigation engaged with a wide range of healthcare staff to learn what impact fatigue had on patient safety in acute NHS hospitals. The investigation explored the NHS systems and processes in place to capture and learn from the risk posed by fatigue on patient safety and staff safety. It also considered the main factors that contribute to healthcare staff being fatigued.

The investigation shares findings from staff interviews, discussions and observational visits to several acute hospital trusts, combined with evidence from national bodies, forums and networks with insight on this topic. The report also refers to supporting surveys and literature.

While the investigation focused on staff working in acute hospitals, the findings will be relevant to providers and staff in other health and care settings.

Findings

Staff fatigue contributes directly and indirectly to patient harm. However, there is little evidence available to help understand the size and scale of the risk, how it impacts on patient safety, and those staff groups who may be most at risk of fatigue.
There was variation in how the concept of fatigue was understood and the impact it could have on patient safety and staff safety across the healthcare system. This inconsistent understanding prevented fatigue risks being addressed.
The risks posed by staff fatigue are not always clear to trusts. The systems and processes needed to provide the information to assess staff fatigue risk are not always well developed or well used. However, some trusts were starting to explore these risks.
A positive safety culture was a key enabler to support healthcare organisations to recognise and manage fatigue risk.
Staff fatigue is not routinely captured as part of patient safety event reporting or routinely considered as part of patient safety event learning, or other governance processes.
Fatigue was perceived by organisations and staff as an individual staff risk, with limited organisational accountability. This sometimes led to a blame culture and punitive actions when staff were fatigued, and limited actions to drive improvement.
Fatigue arises from a number of personal and organisational factors, which can overlap. Organisational factors that contributed to staff fatigue included workload, long shifts, insufficient rest facilities and inadequate rest breaks during and between shifts. Personal factors that contributed to an increased risk of fatigue included caring responsibilities, menopause, pregnancy, religious practices and socioeconomic factors.
Fatigue was found to have a negative impact on staff safety. A key risk related to this was staff driving home after a long shift and being involved in fatal car accidents or near misses.
There are barriers to acknowledging the risk posed by staff fatigue. These include historical beliefs and norms around working long and additional hours, pride and ‘heroism’ of NHS staff.
The demands on healthcare services, and workforce and financial constraints, limited the ability of some organisations to address fatigue risks.
There is limited regulatory and national oversight of the risks posed to patient safety by staff fatigue in healthcare.
There was limited consideration of the risk of staff fatigue in national initiatives addressing workforce challenges and care delays.
The systems-based approach and supporting materials provided to trusts implementing the NHS England Patient Safety Incident Response Framework (PSIRF) helped to prompt consideration of staff fatigue in safety event learning, but this was not routine in all organisations.

Safety recommendations

NHS England |

Department of Health and Social Care

HSSIB recommends that NHS England/Department of Health and Social Care identifies and reviews any current processes that may capture staff fatigue related data. The output of the review should identify how information about factors impacting on staff fatigue can be collated and further enhanced to aid the understanding of fatigue risk in healthcare. This data will help inform the development of any future strategy and action to address staff fatigue risk and its impact on patient safety.

The Department of Health and NHS England accept this recommendation and recognise the serious impact of staff fatigue and burnout on NHS staff. This year’s NHS Staff Survey 2025 results indicate that burnout is still a continuing area of concern. We expect boards and leaders of local NHS organisations to play a key role in addressing these issues through workforce planning and fostering positive, supportive working environments.

Significant action is already underway to improve staff health and wellbeing. The 10 Year Health Plan introduces new staff standards for modern employment and developed through close engagement with the Social Partnership Forum. These will launch in April 2026 to support healthy and flexible working, and other issues of importance to staff. The 10 Year Health Plan also set out that Staff Treatment Hubs would be established along with high‑quality occupational support to NHS staff. Staff wellbeing is also a central component of the 10 Year Workforce Plan due for publication in Spring 2026.

Robust data is essential for understanding the impact of fatigue on patient safety and informing effective strategies. NHS England collects regular staff experience data through the Pulse Survey, including access to rest spaces. The 2021 NHS Staff Survey incorporated the Copenhagen Burnout Index to measure levels of personal, work‑related, and client‑related exhaustion. Providers are able to triangulate these results in combination with other datasets including patient safety incidents.

Actions planned to deliver safety recommendation:

DHSC is in regular contact with NHS Employers through our quarterly reporting process and general informal discussions. We have used these opportunities to hear more about the work that is being taken forward to address the action set out in recommendation 2 of HSSIB’s report on the impact of staff fatigue on patient safety.

DHSC/NHSE will use these regular opportunities to hear more about the emerging definition from the Health, Safety and Wellbeing group. These findings will be reflected in developing work between NHSE/DHSC and particularly in relation to health and wellbeing initiatives for NHS staff. There will also be an opportunity to understand more about the impact of staff fatigue on patient safety as work develops on the projects included in the Workforce Wellbeing Programme. By when: ongoing. Resources in place to deliver actions: DHSC/NHSE officials. Other dependencies identified: The Workforce Wellbeing Programme is a £10 million partnership with NHS Charities Together and NHS England. The programme funds activity at a local level to improve and sustain the health and wellbeing of NHS staff. There are two specific projects that are relevant to the work of HSSIB and their work on staff fatigue and the impact on patient safety. St George’s Hospital Charity and University Hospitals Bristol and Western Charity have been successful in being awarded grant funding for projects relating to staff fatigue. These will be important as we strive to improve the health and wellbeing of staff. Both projects will provide additional data sources to enable DHSC/NHSE to deliver on the action set out in this report. Importantly, there will be future opportunities, once the projects have been evaluated, for best practice to be spread and scaled, with other trusts adopting these approaches within their organisation. NHSE work very closely with NHSCT on this programme and are proactive in providing updates and developments on the work that is underway. Additional comments: Although there is still a legislative process to complete on the merger of DHSC and NHSE, joint working between both organisations has already commenced. This includes partnership working on the new staff standards identified in the 10 Year Health Plan which have a strong focus on improving the experience of staff in the workforce, with health and wellbeing identified as major factors to be addressed. The standards will be published in April 2026. In addition to the standards, the 10YHP also set out plans to roll out staff treatment hubs to ensure that all staff have access to high quality treatment for mental health and musculoskeletal conditions. Work on the development of the 10 Year Workforce Plan is also underway and due to be published in Spring 2026.

Response received on 2 April 2026.

NHS Staff Council

HSSIB recommends that the NHS Staff Council, via the Health, Safety and Wellbeing subgroup, convenes fatigue science experts and other key stakeholders to develop and test a consensus statement defining fatigue for all healthcare staff. The group should work with existing networks to promote the definition and a shared understanding of the causes and impacts of fatigue. This will help to support a consistent understanding of fatigue among healthcare providers and improve the understanding of factors that may impact on staff fatigue and patient safety.

The Health, Safety and Wellbeing Group of the NHS Staff Council, welcome the report and recommendations on the impact of fatigue on patient safety. As a group committed to promoting a safer working environment for all healthcare staff, we recognise the impact that fatigue has on staff health, safety and wellbeing and the subsequent impacts on safe and effective patient care. Through our guidance on the Health, Safety and Wellbeing of Shift Workers and supporting infographic, the group has previously recognised that shift work, if not managed safely, can present a significant risk of fatigue and that local policies and practices need to go beyond the requirements of the Working Time Regulations. Whilst the group has health, safety and industrial expertise, we recognise there are experts in fatigue and human factors within health, care and other industries. Therefore, we will collaborate with our current stakeholders and consult HSSIB for guidance on reaching out to additional stakeholders. In addition to the work highlighted below, we will also review existing guidance relating to staff health, safety and wellbeing to ensure our messaging aligns.

Actions planned to deliver safety recommendation:

Phase 1 - stakeholder mapping, by end of February 2026. Resources in place: Support of NHS Staff Council Secretariat. Other dependencies identified: Includes experts in human factors in fatigue, workplace safety regulators and those who have carried out work in this area (both inside and outside NHS). Additional comments: We will collaborate with our current stakeholders and consult HSSIB for guidance on reaching out to additional stakeholders.
Phase 1 - scoping work, by end of February 2026. Resources in place: Support of NHS Staff Council Secretariat. Additional comments: Scope will not look at direct impacts on patients as this is not within the terms of reference of the group (previously made clear to HSSIB).
Phase 2 - Stakeholder roundtable event to inform the consensus statement, by April 2026. Resources in place: Support of NHS Staff Council Secretariat.
Phase 2 - Drafting and testing the consensus statement, by end July 2026. Resources in place: Support of NHS Staff Council Secretariat.
Phase 2 - Publication and launch via webinar/social media activity and through member networks, by end September 2026. Resources in place: Support of the NHS Staff Council Secretariat and the NHS Employers communication team. Other comments: Members of the group will use their existing networks.

Response received on 10 July 2025.

Safety observations

HSSIB makes the following safety observations:

Research funding and commissioning bodies can improve patient safety by prioritising future research to measure and assess the impact of staff fatigue on staff and patient safety. This should include patient experience and the health economics of staff fatigue due to reduced performance and productivity.
Healthcare organisations and professional bodies can improve patient safety by including aspects of fatigue when conducting staff surveys in order to help build an understanding of the level of fatigue and any impact on staff performance and patient safety. This will help organisations assess and understand the risks associated with staff fatigue, and to monitor and manage the risk of staff fatigue.
Healthcare regulators and professional bodies can improve patient safety by: considering how they can contribute to driving improvement in the understanding and awareness of staff fatigue; considering how they can support and share best practice on mitigations for the risk of staff fatigue; considering organisational and individual factors that may have contributed to staff fatigue when making decisions about regulatory assessment and action.
Government and national organisations can improve patient safety by accounting for the impact of staff fatigue on patient safety when developing national priorities for NHS services.
Healthcare organisations can improve patient safety by considering the principles and activities for a systems approach to fatigue risk management and the roadmap to implement this as described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’.

Safety actions

Local-level learning prompts

HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level.

Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Does your organisation consider fatigue risk when responding to patient safety events
Does your organisation have a person responsible for leading on fatigue risks?
Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Does your organisation consider how the design of work processes can help to reduce fatigue?
Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Does your organisation measure and monitor data relating to fatigue risks?
Does your organisation’s risk register identify fatigue risks?
Has your organisation considered the principles and activities described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’?