The impact of staff fatigue on patient safety
Published
NHS staff
Patient safety themes
Staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share safety recommendations and learning for healthcare organisations to increase their understanding of staff fatigue. This includes the need to review existing data to better understand factors that impact on staff fatigue and steps NHS trusts …
2 recommendations
5 observations
10 actions
10 learning prompts
1 of 2 responded
Safety Recommendations (2)
NHS England
R/2025/061
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.
Trafford Council
R/2025/062
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 NHS Staff Council plans to convene experts and stakeholders to map, scope, draft, test, and publish a consensus statement defining fatigue for healthcare staff by September 2026.
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 (5)
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 (10)
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’?
Learning Prompts (10)
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’?