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The impact of staff fatigue on patient safety

Published 24 April 2025 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 …

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Summary

2 recommendations 5 observations 10 actions 10 learning prompts 2 of 2 responded

Safety Recommendations

2 total
R/2025/061 NHS England
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 the recommendation, noting existing data sources and ongoing engagement with NHS Employers. They will use regular opportunities to understand emerging definitions and leverage two funded projects for additional fatigue data.
Response received 2 April 2026
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.
R/2025/062 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 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.
Response received 10 July 2025
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 total
Observation 1 Observation 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.
Observation 2 Observation 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.
Observation 3 Observation 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.
Observation 4 Observation 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.
Observation 5 Observation 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 total
Action 1 Action Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Action 2 Action Does your organisation consider fatigue risk when responding to patient safety events
Action 3 Action Does your organisation have a person responsible for leading on fatigue risks?
Action 4 Action Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Action 5 Action Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Action 6 Action Does your organisation consider how the design of work processes can help to reduce fatigue?
Action 7 Action Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Action 8 Action Does your organisation measure and monitor data relating to fatigue risks?
Action 9 Action Does your organisation’s risk register identify fatigue risks?
Action 10 Action 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 total
Prompt 1 Learning prompt Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Prompt 2 Learning prompt Does your organisation consider fatigue risk when responding to patient safety events
Prompt 3 Learning prompt Does your organisation have a person responsible for leading on fatigue risks?
Prompt 4 Learning prompt Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Prompt 5 Learning prompt Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Prompt 6 Learning prompt Does your organisation consider how the design of work processes can help to reduce fatigue?
Prompt 7 Learning prompt Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Prompt 8 Learning prompt Does your organisation measure and monitor data relating to fatigue risks?
Prompt 9 Learning prompt Does your organisation’s risk register identify fatigue risks?
Prompt 10 Learning prompt 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’?