Search the hub

Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and the role of human factors within the new Patient Safety Incident Response Framework (PSIRF). Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care and safety. Understand the role of human factors in improving culture and delivering psychological safety. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register We are pleased to offer hub members a free place using the code HCUK00HFPSL

Last month, Public Policy Projects hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. In this article, Patient Safety Learning reflects on the recurrent theme of safe systems and safe cultures.  Safe systems and cultures formed an integral theme throughout the Forum. Across the discussions, one message stood out clearly—safety cannot be something we focus on only when inspections are approaching or when things go wrong. It has to be built into everyday practice. One speaker framed this idea simply—every day should be a CQC (Care Quality Commission) day. Not because staff fear inspection, but because the systems around them consistently support safe care. When systems work well, healthcare professionals can deliver the care they want to give without constantly battling the structures and culture around them. Yet the conversations during the day also highlighted how far many parts of the system still have to go… Fatigue—“I’ll sleep when I’m dead” A significant discussion focused on staff fatigue and the culture that has developed around it in healthcare. Rather than being treated as an exceptional risk, fatigue is something that is just expected. In some cases it has become a misplaced badge of honour—evidence of dedication to the job. The example phrase of “I’ll sleep when I’m dead” resonated with many. A response no doubt born from a sense of utter powerlessness and lack of evidence that things will change. But normalising exhaustion creates unsafe systems for both staff and patients. Senior Nurse, Maggie Pacheco, shared an example from her own experience. After working six consecutive night shifts she was asked to take on a seventh. It did not feel safe, and during that shift a near miss occurred. Her story reflected a wider reality—systems that rely on exhausted staff are systems that increase risk. Sue Strudwick, Patient Safety Partner, highlighted that fatigue also shapes how care is delivered. When staff are constantly depleted, the system pushes them into reactive responses rather than preventative thinking. Creativity, reflection and improvement require energy and time, both of which fatigue removes. If healthcare is serious about safe systems, then fatigue cannot remain normalised. Staff support must be prioritised and built into the design of rotas, policies and expectations. Structural change is required, not symbolic gestures. Staff safety as a foundation of safe systems The forum also highlighted the importance of ensuring that staff themselves feel safe at work. Healthcare workers continue to face violence, harassment, racism and sexual abuse in some workplaces. These experiences damage morale, wellbeing and the ability to focus on patient care. A safe healthcare system cannot exist if the people delivering care do not feel physically and psychologically safe themselves. Protecting staff is therefore not separate from patient safety—it is part of it. When silence signals risk Another strong theme was the importance of psychological safety, particularly when it comes to speaking up and raising safety concerns. Silence in an organisation is sometimes interpreted as stability. In reality, it can indicate the opposite. Panellists described the presence of “shut up signals” within teams and organisations—signals that speaking up is unwelcome or risky. These signals may appear through dismissive responses, defensive leadership or negative consequences after raising concerns. Once staff recognise them, they quickly learn that raising issues carries a personal cost. The impact on patient safety is significant. When staff do not feel able to speak openly about risks or mistakes, organisations lose their early warning systems. Problems remain hidden until they escalate into serious harm. Language and responses after incidents play an important role here. Punitive reactions can discourage openness and suppress learning. Safe cultures, by contrast, make it easier for staff to raise concerns and share information when something goes wrong. Many of the guests in our Speaking up for patient safety interview series highlight the same issues surrounding psychologically unsafe cultures, and the devastating impact this can have on patients and staff. From blame to systems thinking Closely linked to speaking up is the way organisations respond when incidents occur. Healthcare is a complex system where harm rarely results from a single individual’s actions. During the forum, Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB), highlighted the importance of shifting the question from “who is to blame?” to “how did the system allow this to happen?” Frontline staff frequently create workarounds to protect patients when systems or policies do not function well in practice. These adaptations often keep services running safely despite structural weaknesses. If organisations focus only on individual blame, they risk overlooking the system conditions that allowed harm to occur in the first place. A systems approach enables learning and improvement rather than fear and defensiveness. Leadership and culture change Underlying many of these issues is the need for a different style of leadership. Creating safe systems requires leaders who listen, collaborate and engage with those delivering and receiving care. Solutions are more likely to be sustainable when they are developed with frontline staff and patients rather than imposed from above. Working with patients, the public and Patient Safety Partners were repeatedly highlighted as an important part of cultural change. A healthcare system that values patient experience alongside operational metrics is more likely to identify risks early and respond effectively. What organisations measure also shapes their culture. When success is defined solely through activity and productivity, the human experience of care can easily be overlooked. Balanced measures that include safety and experience are essential for creating systems that truly support quality care. Culture is the system The conversations at the Patient Safety Forum made clear that safety cannot be separated from culture. Policies and processes matter, but the everyday behaviours, expectations and norms within organisations matter just as much. Safe systems are created when staff are supported rather than exhausted, when concerns can be raised without fear, and when organisations seek to understand system failures rather than simply assign blame. Changing culture is never quick or easy. But if healthcare systems want to improve patient safety, they must be willing to challenge the norms that have become embedded in everyday practice and redesign systems that allow safe care to happen consistently. Share your insights Have you seen patient safety affected either positively or negatively by culture and systems? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Or you can email our editorial team at [email protected].

Phil Ross is the Chair of the Design in Mental Health Network, Co-Founder of Safehinge Primera, and a Trustee at the Centre for Mental Health (UK). In this blog, Phil describes a collaborative Quality Improvement project that aimed to ensure a door alarm system acted as a trusted safety aid, not a constant distraction. When it comes to service user safety in mental health settings, every second counts. That’s why Aspen Wood, Mersey Care NHS Foundation Trust’s new 40-bed low secure unit for people with learning disabilities, installed 67 full-door ligature alarm systems. The system that invisibly transforms the entire door into a weighing scale, detecting any sustained load and triggering an alert for staff to proactively intervene and save a life. However, frontline NHS teams using full-door ligature alarms and other full-edge systems shared a challenge: frequent false alarms. These alarms are disruptive, distracting, and desensitising. For staff already stretched, these alerts became a barrier to the calm, therapeutic environments we’re all working to create. Not one to shy away, we listened. Then we acted and together, co-launched a Quality Improvement (QI) initiative to solve the issue. The cost of constant alarms in mental health wards Imagine being a nurse on a mental health ward where an alarm sounds 10-20 times every day. Each alarm demands immediate attention – a possible ligature attempt – yet almost every time it turns out to be a false alert. Front-line caregivers were understandably anxious that alarm fatigue – the desensitisation to alarms due to overexposure – could undermine patient safety. The false alarms were also distracting staff from providing care. Alarm fatigue is not a trivial inconvenience; it’s a well-documented clinical risk. In healthcare settings, when clinicians face an overload of alarms, they can become desensitised, leading to slower responses or ignored alerts.[1] In the context of mental health, the stakes are especially high – an ignored alarm could mean a patient death by suicide. Recent findings in the UK have highlighted this danger: an NIHR review noted that “‘alarm fatigue’ associated with surveillance technology use can even have fatal consequences”.[2] Tragically, this was echoed by a real-world incident in Essex, where an 18-year-old patient was found unresponsive after staff failed to respond for over 52 minutes to a bathroom sensor alert. The inquest revealed that staff had grown so accustomed to frequent alerts on their digital monitoring system that “alert fatigue” had set in.[3] Aspen Wood’s alarm challenge: 600+ alerts and a team determined to help At Aspen Wood, the alarm overload soon after installation quickly became recognised as an urgent patient safety and operational issue. The Trust’s leadership moved swiftly, bringing us in to discuss the issue and creating a cross-functional working group to explore ways to resolve it. Around the table were clinicians from the wards, Estates managers, the Trust’s risk and patient safety leads, our team of experts from Safehinge Primera, who developed the full-door anti-ligature alarm, and Pinpoint, who provide the staff attack alarm system that relays door alerts to staff devices. This collective approached the problem to try and understand the issue in greater detail and explore ways to solve it. Everyone agreed on a critical point: expecting zero alarms wasn’t realistic, but we should aim to get as low as possible (there will always be some incidents or tests). The team set an initial target: roughly one ligature alarm per day across Aspen Wood – ambitious yet attainable with the right improvements. Collaborative problem-solving Several concrete solutions emerged from the discussions and subsequent development work: ● Adjusted sensitivity threshold: When the QI team discussed weight sensitivity, the Trust’s Risk team highlighted that the door alarm was much more sensitive than other safety devices within the room - the load release curtain tracks released around 20 kg. Our full door alarm was set to a 7 kg weight threshold, unnecessarily sensitive. Here, the adjustable weight threshold became a big advantage for the Trust, changing to 15 kg for this user group (with the benefit of keeping lighter weight sensitivity when used for people with eating disorders). This change sharply cut false positives without compromising safety (indeed, the team carried out a series of lab tests based on a range of different previous ligature attempts). ● Firmware enhancements and battery life: Our team also rolled out a new approach to greatly improve battery life. The new firmware also introduced smarter data logging – essentially enabling the system to be more intelligent about what triggered it, so that staff could get feedback if improper use of the door was causing alarms (like wedging the door open or hanging objects). These behind-the-scenes tweaks enhanced the system’s robustness and reduced nuisance triggers by providing helpful feedback for staff. ● Localised and silent alerting: Initially, a door ligature alarm at Aspen Wood would broadcast an alert across the entire hospital network via the staff attack alarm system. This meant a single bathroom incident could set off alerts on multiple wards, needlessly alarming staff beyond the affected area. The system was reconfigured so that door ligature alarms now alert only the local ward. This change empowers the ward staff to quickly verify and respond, and, if it is a serious incident, staff can still escalate using their Personal Infrared Transmitter (PIT) alarm. The result is fewer interruptions hospital-wide and a more scalable response protocol. The Mersey Care team had always opted for silent alarms to prevent disrupting service users with learning disabilities, an approach we’re seeing adopted nationally across all care pathways. ● Staff training refreshers: We worked with the Trust to co-create simplified support materials to ensure staff felt confident managing the alarm system. A quick-reference poster was designed (with input from Aspen Wood’s clinical team) to support new or bank staff on how to swiftly reset a door alarm after an incident. Training sessions were scheduled, including hands-on practice using our mobile training unit. This conscientious approach acknowledged that technology is only as effective as the people using it. ● Stronger interface and support: Both Safehinge Primera and Pinpoint also recognised that closer integration and joint support when complex technical issues arise would help Mersey Care’s Estates team resolve issues quickly and easily. We also worked together to create a joint troubleshooting guide for the Aspen Wood team, so any issues could be quickly pinpointed (no pun intended) and resolved. By improving the interface between the two systems and clarifying responsibility, the Trust gained confidence that “issues” would no longer fall into a void between different suppliers, but instead, a collaborative team of experts. Results: from 600 alarms to just 6 – a transformative difference The results were even better than we’d hoped for…not 30 alarms per month, but just 6 alarms. When the stakeholders reconvened at the end of April 2025, our door alarm dashboard evidenced that alarm rates had plummeted. This has restored the alarm system to its intended role: a trusted safety aid, not a constant distraction. Reliability through the system's continual monitoring (avoiding the costly daily check requirements from push-bar, door edge type alarm systems) and adjustable weight sensitivity meant the alarms were keeping staff focused on time to care, whilst ensuring service user safety too. “The current pressure on frontline teams is huge, so when the built environment adds noise instead of support, it’s a problem that Estates are asked to resolve quickly. What made this initiative work was the openness on all sides. Together, we made the Safehinge Primera full-door ligature system smarter and safer for everyone, and something that we hope will help other NHS Trusts across the country.” Chris Murphy, Assistant Director of Estates and Facilities, Mersey Care NHS Foundation Trust A model for best practice: hopeful lessons beyond Aspen Wood The journey at Aspen Wood carries hopeful lessons for mental health facilities everywhere. Alarm fatigue in an inpatient mental health setting is not an insurmountable fate; it’s a challenge that can be overcome through empathetic, curious, and determined collaboration. Mersey Care didn’t shy away from flagging the problem, and in partnership with suppliers, they created the space to carry out an analysis and co-create solutions. The outcome made our alarm smarter, more user-friendly, and tailored to the ward’s needs. In doing so, they upheld a core principle of patient safety: technology must augment, not hinder, the human care process. This story also underlines a broader point in NHS mental health services: collaboration and continuous improvement are key. Just as we strive to co-produce care with service users, here we see collaboration between clinicians, engineers, and estates teams. The result – a dramatic reduction in alarms and a safer, calmer ward – speaks to the power of being conscientious (putting service user and staff needs first) and determined (not giving up on a good idea, even when it hits bumps in the road). By staying curious (asking “Why is this happening? How can we fix it?”) and maintaining a positive mindset that a solution would be found, the Aspen Wood team exemplified the best of NHS innovation culture. Looking ahead, Mersey Care’s Aspen Wood can serve as a model of best practice that we’re actively rolling out with other mental health Trusts. References 1. HSSIB. Investigation report: The impact of staff fatigue on patient safety. 2025. (Accessed online 11.02.26). 2. Griffiths JL, Saunders KRK, Foye U et al. The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: a systematic review (preprint). 2024. (Accessed online 11.02.26). 3. BBC News. Essex mental health patient died despite staff alarm – inquest. (Accessed online 11.02.26) Further reading Reiter-Millard B. Tackling Alarm Fatigue. Safehinge Primera. 2025. (Accessed online 11.02.26) Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

The NHS has served millions of people over decades. It stands as a symbol of collective care, public service and professional commitment. That history matters. It deserves respect. But patient safety does not rest on history alone. It rests on people. And people need safe systems to do safe work. Today, those systems are under strain in ways that should concern us all. This piece is not about blame. It is about learning, and about starting a conversation that is long overdue. Psychological safety is not optional in patient safety The patient safety literature is unambiguous on this point. Staff must feel safe to speak up, to report concerns, to admit uncertainty or error. When they do not, harm follows. Psychological safety is the foundation that enables incident reporting, learning from error, early risk escalation and team-based decision-making. Amy Edmondson's landmark research established this link decades ago,[1] and the NHS has echoed it repeatedly through policy and inquiry.[2] Research confirms that when psychological safety is present, the benefits extend across individuals, teams and organisations. A recent systematic review found that a positive safety culture leads to both workforce wellbeing and improved patient outcomes, including lower rates of surgical site infections, falls and medication errors. Yet when fear enters the system, silence grows. And silence, in healthcare, can be lethal. The exodus: workforce loss as a patient safety risk The NHS is losing people it cannot easily replace. Experienced clinicians are retiring early. Skilled staff are leaving for overseas systems offering better pay and conditions. Capable professionals are exiting after bruising disciplinary or capability processes. Energetic, committed staff are burning out and disengaging, sometimes quietly, sometimes dramatically. The scale is sobering. Recent data indicates that almost 9,000 internationally recruited nurses leave the UK annually, with the largest increases among those with three years or fewer on the register. The UK risks becoming merely a staging post in their careers rather than a destination. Each departure removes institutional memory, clinical judgement built over years, and the informal safety checks that never appear in any policy document. When experienced staff leave, learning leaves with them. This is not simply a workforce planning issue. It is a patient safety issue. Burnout: structural, not individual Burnout is too often framed as a failure of personal resilience, as though the solution lies in yoga classes and mindfulness apps. That framing is wrong, and it is dangerous. The evidence points clearly to system conditions: excessive workload, role overload, constant organisational change, inadequate staffing and fear of blame. The 2024 NHS Staff Survey revealed that 42% of staff felt unwell due to work-related stress in the preceding 12 months, while 30% reported feeling burnt out because of their work.[3] Perhaps most troubling, 29% said they often think about leaving. These are not personal failings. These are system failures manifesting through individuals. The consequences for patient safety are direct. Research demonstrates that clinicians experiencing burnout are approximately twice as likely to make errors in diagnosis or prescribing.[4] A systematic review of 21 studies confirmed an association between burnout and worsening patient safety outcomes.[5] When staff become unwell, the system becomes unsafe. Debanding: devaluing an already stretched workforce As if burnout, role expansion and workforce exodus were not enough, staff now face another threat: debanding. Across the NHS, roles are being downgraded—responsibilities remain or compound, but pay decreases. This is happening against the backdrop of a cost-of-living crisis that has already eroded real-terms earnings for healthcare workers.[6] The message this sends is unmistakable: you are worth less than you were yesterday, even as we ask more of you today. Staff who are already navigating violence from patients and the public, who are already managing unsustainable workloads, who are already questioning whether they can continue, are now being told their contribution merits a lower band. What do the unions say? What do the regulators say? What does this do to morale, retention and, ultimately, patient safety? These are not rhetorical questions. They deserve answers—from policymakers, from employers and from professional bodies. Silence on this issue is complicity in the erosion of the workforce. Role expansion without preparation: a recipe for risk The NHS is undergoing rapid role reconfiguration. New titles are appearing. Responsibilities are expanding. Scopes of practice are broadening. Change itself is not the problem. Unprepared change is. Across the service, staff are being asked to absorb additional responsibilities, sometimes without consultation, often without adequate training, and frequently without recognition that their original role was already demanding enough. Job descriptions expand while support contracts. Expectations inflate while preparation time vanishes. The evidence from healthcare reengineering efforts both in the UK and internationally shows that role redesign fails to deliver safety or efficiency gains when training is inadequate, supervision is stretched, accountability is unclear and time for development is absent. Research has found that reengineering without integrative and coordinative efforts may actually damage an organisation's position rather than improve it.[7] Classic safety literature warns that poorly implemented role substitution increases task overload, decision ambiguity, near misses, and latent safety failures, the hidden vulnerabilities that lie dormant until circumstances align to cause harm. Capability must come before expectation. When it does not, patients bear the risk. When systems fail, individuals pay the price When incidents occur in pressured systems, what happens next matters enormously. Too often, context is stripped away. System factors are minimised. Individuals carry the weight of failure that belongs, at least in part, to the organisation. This creates a chilling effect that radiates far beyond the person directly involved. Staff learn quickly: speak up and risk your career, or stay silent and survive. Neither option protects patients. A learning culture cannot coexist with fear. The Patient Safety Incident Response Framework (PSIRF) was designed to address this: to shift focus from blame to learning, from punishment to improvement. But implementation without genuine psychological safety risks repeating old patterns dressed in new language.[8] The words change; the fear remains. Have we seen this before? Yes. History offers warnings we would be wise to heed. Mid Staffordshire taught us what happens when fear, silence and understaffing converge: catastrophic harm, public inquiry, costly reform, years of recovery and permanent loss of trust.[9] International health systems under austerity have demonstrated the same pattern repeatedly: workforce loss followed by quality collapse. The United States healthcare system offers its own cautionary tale of burnout, defensive practice, litigation spirals and widespread moral injury among clinicians. The aftermath is always the same. And prevention is always cheaper; in money, in lives, and in trust, than repair. Is the NHS crumbling or being stripped of its foundations? This is the uncomfortable question that demands honest consideration. An overwhelmed workforce cannot deliver safe care indefinitely. A fearful workforce cannot learn. A depleted workforce cannot mentor the next generation or preserve the institutional knowledge that underpins safe practice. Lord Darzi's 2024 independent investigation painted a sobering picture, noting grave concerns over staff wellbeing and a sharp decline in the trust, goodwill and discretionary effort of staff.[10] There is a growing sense that healthcare workers are less willing to tolerate poor conditions from their employers, not because commitment has weakened, but because endurance has limits. Patient safety ultimately depends on psychological safety, adequate preparation, just responses to error and valuing people as safety assets rather than liabilities. The NHS still has extraordinary people. But goodwill is not infinite. And we cannot keep drawing on reserves without replenishing them. What needs to change? Drawing on established patient safety principles, action must include: Embedding psychological safety as a measurable safety outcome, not merely an aspiration. Treating workforce attrition as a patient safety signal that demands investigation and response. Matching role expansion with structured capability building, supervision and realistic timeframes. Protecting learning-focused responses after harm, ensuring that system factors receive the same scrutiny as individual actions Capturing knowledge before experienced staff leave, so that learning is not lost with each departure. These are not radical proposals. They are established safety fundamentals that we already know work. The challenge lies not in discovering new solutions but in implementing the ones we have. An invitation to share your thoughts This piece is not a verdict. It is an invitation to reflect and to speak. The NHS belongs to the public. Its safety depends on its people. And its future depends on our willingness to have honest conversations about what is happening and what must change. I would be enthusiastic to hear from colleagues across different cadres and contexts. Frontline clinical staff, middle managers, senior leaders, policymakers, regulators and, crucially, patients and families all hold pieces of this picture. Our perspectives may reveal quite different experiences of workforce changes and their implications for safety. What are you seeing in your part of the system? What feels unsafe that is not being discussed? What learning is being lost? And what is debanding doing to your team, your morale, your ability to deliver safe care? I welcome perspectives from frontline staff, union representatives, regulators, and anyone willing to speak honestly about what is happening. Please comment below. You will need to be a hub member (sign up is free and easy to do) and signed in. References Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Hoboken, NJ: John Wiley & Sons, 2018. West M, Bailey S, Williams E. The Courage Of Compassion: Supporting Nurses And Midwives To Deliver High-Quality Care. The King's Fund, 23 September 2020. NHS England. NHS Staff Survey Results, 2024. Garcia CL, Abreu LC, Ramos JLS, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas) 2019; 30;55(9):553. doi: 10.3390/medicina55090553. PMID: 31480365; PMCID: PMC6780563. Hall LH, Johnson J, Watt I, et al. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS One 2016; 8;11(7):e0159015. doi: 10.1371/journal.pone.0159015. PMID: 27391946; PMCID: PMC4938539. House of Commons Health and Social Care Committee. Workforce burnout and resilience in the NHS and social care, 2021. Leatt P, Baker GR, Halverson PK, Aird C. Downsizing, reengineering, and restructuring: long-term implications for healthcare organizations. Front Health Serv Manage 1997;13(4):3-37; discussion 52-4. PMID: 10167281. Patient Safety Learning. Mind the Implementation Gap, 2022. Francis R. Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013. Lord Darzi. Independent Investigation of the National Health Service in England. Department of Health and Social Care, 2024.

On the 20 January 2026, a selection of Patient Safety Partners who are also members of the Patient Safety Partners Network, wrote to a number of key stakeholders outlining their concerns around healthcare worker fatigue and calling for action.  The letter was sent to: Wes Streeting MP, Secretary of State for Health and Social Care Baroness Merron, Parliamentary Under-Secretary of State (with portfolio responsibility for patient safety) Dr Aiden Fowler, National Director of Patient Safety and NHS England Professor Henrieta Hughes, Patient Safety Commissioner for England Layla Moran MP, Chair of the Health and Social Care Select Committee Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety Danny Mortimer, Chief Executive of NHS Employers The content of the letter can be viewed below. 20 January 2026 Dear [RECIPIENT] We are writing to you on the issue of healthcare worker fatigue and its impact on patient safety. The signatories of this letter are all members of the Patient Safety Partners Network. The Network is composed of Patient Safety Partners, in both paid and voluntary positions within NHS organisations, whose role is to improve patient safety. It is hosted on the hub by the charity Patient Safety Learning, who provide a monthly drop-in session, sometimes with guests, to talk through topical and relevant issues. This facilitates information sharing, peer support and safe space for discussion. Fatigue poses serious risks to both the wellbeing of staff and safety of patients. Healthcare workloads are often heavy, stressful and involve complex decision making – however we lack robust fatigue risk management systems that exist in other safety-critical industries. At a recent Network session focusing on fatigue, we were joined by Dr Laura Pickup, Head of Human Factors at University Hospitals Bristol and Weston NHS Foundation Trust and a member of the organising committee for the Healthcare Fatigue Forum. The discussion highlighted several key issues: Fatigue in healthcare has become normalised, with staff continuing to work while exhausted, unlike in other safety-critical industries where controls are in place to prevent fatigue-related risks. Fatigue is a systemic issue, not an individual failing. It must be recognised through existing governance and risk management processes. Addressing fatigue requires leadership, organisational commitment, and system-level change, not simply individual resilience. Fatigue can be a contributor to avoidable harm and must be formally recognised as such within safety investigations. Staff should be empowered to speak up when they are too fatigued to work safely. Our Call to Action We are asking that every healthcare organisation formally adds fatigue to its organisational risk register. By doing so, each organisation would be required to: Risk assess the impact of fatigue on both staff and patient safety. Identify mitigation and management actions to reduce fatigue-related risks. Monitor progress and outcomes through established governance systems. Recognising fatigue in this way is not merely a procedural step—it is an essential act of leadership and accountability. It acknowledges that fatigue is a significant, system-level patient safety risk and ensures that it is managed with the same rigour as other high-impact safety concerns. We would also welcome the following complementary actions: Inclusion of fatigue as a contributing factor in investigations under the Patient Safety Incident Response Framework (PSIRF), where relevant. Endorsement and amplification by the Department of Health and Social Care, NHS England, and individual NHS organisations of the work being done by the Healthcare Fatigue Forum and the #FightingFatigue campaign to raise awareness and share best practice. We would welcome your response and support for our call to action. I look forward to your response in due course. Yours sincerely, 12 signatories were included (Members of the Patient Safety Partners Network).

The Fatigue Severity Scale (FSS) was developed by Lauren B. Krupp, Nicholas G. LaRocca, Joseph Muir-Nash, and Alfred D. Steinberg. First published in 1989 in the Archives of Neurology, the FSS has since become a cornerstone in fatigue assessment. Indeed, its significance is underscored by over 7000 citations on Google Scholar, highlighting its widespread adoption and utility in both clinical and research settings. Consequently, professionals can leverage this tool to enhance patient care and advance research in conditions where fatigue is a prominent symptom. This article offers an in-depth exploration of the FSS, providing researchers and clinicians with actionable insights into its structure, validation, applications, and overall value in understanding and managing fatigue.

The Patient Safety Partners Network (PSPN) includes Patient Safety Partners, in both paid and voluntary roles within NHS organisations, whose role is to improve patient safety. Patient Safety Learning provides a monthly drop-in session for the PSPN, sometimes with guests, to talk through topical and relevant issues. This facilitates information sharing, peer support and safe space for discussion.  The network met in October to discuss the topic of staff fatigue and its impact on patient safety, with an excellent presentation by Dr Laura Pickup.  In this blog Sue Strudwick, the Patient Safety Partner who chaired that meeting, reflects on the session and some of the key points raised by Laura and the members.  Dangerously normalised Fatigue in the NHS is a long-standing issue, one of the most persistent and often under-recognised. Many systems and rotas are built on the assumption that people will work long shifts, skip breaks, and pick up extra hours to make ends meet or fit around family life. For many staff, long shifts offer flexibility, but the cost can be impaired judgement leading to poorer care. Fatigue has become normalised, with staff continuing to work when exhausted, whereas in aviation and transport, strategies are in place to try to prevent fatigue impacting on safety. There’s also a collective fatigue across the NHS — exhaustion from years of uncertainty and constant change. Culturally, rest is often frowned upon. Few proper rest spaces exist, and napping or having a ‘proper’ break is often felt to be unacceptable. Staff may even fear that admitting to fatigue will lead to questions about whether they are up to the job. Fatigue is not a human resource issue – it’s a patient safety issue. Adding fatigue to risk registers When exhausted staff are making complex decisions, the consequences and risk to patients can be serious. Fatigue isn’t just about the individual staff member; it’s a systemic problem. Every healthcare organisation should have fatigue on its risk register because of its undeniable impact on patient safety. Part of the problem is that, unlike aviation or transport, healthcare still lacks a clear definition of fatigue. The Health and Safety Executive has one that could be used in the interim, so organisations do not need to wait before taking action. Regulation of fatigue risk management exists in other industries and should be part of regulation within the NHS. The need for strong leadership Addressing fatigue requires strong leadership and high-level backing. This isn’t about reminding individuals to ‘look after themselves’ — it needs a systems approach. Fatigue risk management should be treated like any other safety system, collecting and triangulating data from surveys, incident reports, and occupational health. Rostering and shift scheduling should support rest and recovery. High-risk groups, including mental health trusts, must be included. The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) both acknowledge fatigue as a risk factor in adverse events, yet systemic solutions are still lagging behind the scale of the problem. Co-designing rostering solutions The NHS would struggle to function if every staff member worked strictly within fatigue limits. But that can’t justify accepting the status quo. Crucially, any solution must be co-designed with staff. Fatigue is a human issue, and change must balance patient safety, wellbeing, and service provision. Co-design helps ensure any policy works in practice — for patients and professionals alike. Healthcare support workers — who often work the longest hours for the lowest pay, especially need support. There also needs to be open thinking about creative solutions: could volunteers help reduce pressure if better supported? Are occupational health and wellbeing services being fully used? Final thoughts Fatigue is often one factor, in many, contributing to avoidable harm. The challenge of addressing the impact on patient safety is huge, but fatigue can be managed, mitigated, and made visible. We can start by formally recognising it as a risk, embedding fatigue management in safety culture, and highlighting it in Patient Safety Incident Investigations. Staff need to be empowered to speak up when they’re too fatigued to work safely. Patient Safety Partners can help shine a light on staff fatigue, its impact on patient safety and call for it to be added to risk registers throughout the NHS. How to join the Patient Safety Partners Network The Patient Safety Partners Network meets monthly in a virtual capacity and now includes nearly 200 Patient Safety Partners. These meetings provide a supportive and safe space for Patient Safety Partners to: discuss barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working within NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. Related reading Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan HSSIB Investigation report: The impact of staff fatigue on patient safety (24 April 2025) Fighting Fatigue Together campaign Share your insights Have you seen the impact of fatigue on patient safety? Have you personally been affected as a member of staff or a patient? Share your thoughts by commenting below (sign up here for free first) or you can contact our editorial team at [email protected].

Staff engagement has a significant and demonstrable impact on patient safety in the UK, especially within NHS trusts. Caroline Beardall shares some of the research and recommendations for focus and action. The correlation between staff engagement and patient safety Rising patient safety concerns and high-profile failures, staff burnout and turnover, and morale challenges post-Covid, along with increased scrutiny and accountability from the the Care Quality Commission (CQC) and the Patient Safety Incident Response Framework (PSIRF), has led to disengaged staff. Research has shown that staff engagement levels impact care quality and has been linked to patient mortality. A longitudinal study using seven years of NHS Staff Survey data found that trusts with higher staff engagement tend to have lower inpatient mortality rates, as measured by SHMI (Summary Hospital-level Mortality Indicator). Conversely, higher mortality also predicts lower engagement, suggesting a feedback loop between the two. The study concluded that increasing engagement could be an actionable route to improving patient outcomes.[1] A global meta-analysis (including UK settings), of 11 studies involving over 30,000 staff, found a statistically significant correlation between staff engagement and better safety outcomes. This suggests engagement consistently aligns with healthier safety cultures and fewer mistakes—even if causality isn't fully confirmed.[2] While the general evidence is strong, UK-specific studies (from NHS settings) remain relatively few. A narrative review notes most UK data are from staff surveys or limited empirical studies, often cross-sectional and relying on self-report. [3] However, the overlap with UK meta-analyses and international findings supports the relevance of these associations to NHS practice. Cultural and organisational factors Several recent UK investigations show how poor engagement and toxic workplace culture compromise patient safety: University Hospitals Sussex NHS Trust: A review under police investigation for dozens of patient deaths highlighted a culture where staff feared raising concerns due to retaliation or bullying. NHS Greater Glasgow & Clyde (Scotland): Internal reports citing management failures, poor teamwork and a culture of cover-up concluded that these issues “posed risks to patient safety” . Lucy Letby and other maternity scandals: Multiple high-profile NHS inquiries have emphasised that failure to listen to staff or allow whistleblowing correlates with catastrophic outcomes in child safety . In each case, the lack of psychological safety and open communication was tied to preventable harm. We must start treating staff engagement as a clinical priority. Why engagement matters for safety Better error reporting: Engaged staff are more likely to report near-misses and safety concerns, which supports proactive learning and system improvements . Stronger safety culture: Teams with positive leadership, good moral support, and inclusive practices (e.g. psychological safety, participatory management) foster an environment where raising issues is encouraged.  Reduced burnout and turnover: Higher engagement correlates with lower burnout, better staff retention, and less absenteeism—all of which reduce risk and preserve continuity of safe care . The table below summarises the impact of staff engagement on patient safety: Recommendations for NHS leaders and policymakers So how can we improve staff engagement? Here are some evidence-based suggestions: Invest in engagement-focused interventions. Programmes that build inclusive leadership, team‑based decision‑making and psychological safety can reduce errors and mortality. Create the environment for staff to speak up without fear. Strengthen Freedom‑to‑Speak‑Up frameworks and ensure whistleblowers are supported—not penalised—so safety risks are surfaced early. Use data to drive mutual learning. Trusts with high engagement should share best practices with lower‑performing trusts, building a culture of positive deviance. Embed systemic tools and feedback loops. Frameworks, like PSIRF, should intentionally engage staff in incident investigation and learning. Conclusion In summary, staff engagement is a key lever for improving patient safety in UK healthcare: from reducing mortality and adverse events to promoting openness, reporting and continuous learning. Strengthening organisational culture, trust and leadership around engagement is essential to safer, more resilient care. References Badgett RG, Jonker L., Xirasagar S. Hospital workforce engagement and inpatient mortality rate: Findings from the English National Health Service staff surveys. Journal of General Internal Medicine, 2020; 35(12), 3465–70. Janes G, Mills T., Budworth L, et al. The association between health care staff engagement and patient safety outcomes: A systematic review and meta-analysis. Journal of Patient Safety, 2021; 17(3), 207–16. Bailey C., Madden A., Alfes K., et al. Evaluating the evidence on employee engagement and its potential benefits to NHS staff: A narrative synthesis of the literature. Health Services and Delivery Research, 2015; 3(26). Further reading on the hub: Speak Up for Safety: A new workshop for healthcare staff about the importance of Just Culture Staff Support Guide - Patient Safety Learning Key themes emerging from our ‘Speaking up for patient safety’ interview series Swimming with the tide, a blog by Sally Howard