HSSIB Investigation report: The impact of staff fatigue on patient safety (24 April 2025)

Summary

This Health Services Safety Investigations Body (HSSIB) report follows on from HSSIB's launch report, ‘Fatigue risk in healthcare and its impact on patient safety’, which introduced the concept of fatigue and outlined the risk posed to patient safety from staff fatigue. The International Civil Aviation Organization’s definition of fatigue was adopted by this investigation, where fatigue is defined as:

“A physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, circadian phase [the natural daily internal body clock], and/or workload (mental and/or physical activity) that can impair a person’s alertness and ability to perform safety related operational duties.”

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.

Content

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

• 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.
• 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.

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’.

Related reading on the hub:

• Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan
• Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett
• CIEHF: Fatigue risk management for health and social care