The report examines the impact of staff fatigue in healthcare on patient safety. We found, despite some data from surveys and staff anecdotes on exhaustion and fatigue, there is still little evidence available to help understand the size and scale of the problem, the scale of its impact on patient safety and those staff who are at most at risk from fatigue. The healthcare sector lacks robust systems to monitor and manage this issue, even as demands on the NHS workforce become more challenging and intense.
Drawing on interviews, site visits, national data, and expert insight, the investigation found that staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely captured or considered in patient safety event reporting or learning reviews.
Critical safety risk
Our report highlights that fatigue in healthcare is often misunderstood, viewed primarily as a wellbeing concern rather than a critical patient or staff safety risk.
Although individual actions by staff can help to mitigate fatigue, this narrow perception leads to fatigue being treated only as an individual issue, with limited organisational accountability. The report highlights how this misunderstanding can create a culture of blame.
Staff shared concerns about speaking up when fatigue may have contributed to patient safety incidents, fearing disciplinary action from their employers or professional bodies. This culture discourages transparency and hampers opportunities for system-wide learning and improvement.
Our report highlights that a positive safety culture is key to managing this risk. Some NHS trusts are already making progress. For example, using fatigue-related questions in incident reports to identify gaps. In contrast, other safety-critical industries treat fatigue as a recognised hazard by organisations and is supported by formal fatigue risk management systems.
Key findings and safety recommendations
The following points highlight additional key findings.
- Fatigue is linked to preventable patient harm and staff safety incidents, including fatal road accidents post-shift. Staff who spoke to HSSIB told us of colleagues they had known who had lost their lives in road accidents where fatigue was thought to be a contributory factor.
- Organisational and personal factors – such as shift length, lack of breaks, caring responsibilities, and socioeconomic pressures – contribute to fatigue.
- Cultural norms in the NHS as a caring profession, including pride, heroism and long working hours, discourage open conversations about fatigue and is a barrier to acknowledging the risk.
- Fatigue risks are not consistently captured in data or addressed in governance or safety learning systems. There is also limited consideration of the risk of staff fatigue in national initiatives addressing workforce challenges and care delays.
The report concludes with two safety recommendations aimed at developing, reviewing and improving data capture mechanisms on fatigue and establishing a consensus definition of fatigue for healthcare.
The report also contains local learning prompts to encourage a response to the risk at an NHS trust level.
Investigator’s view
Saskia Fursland, Senior Safety Investigator at HSSIB, says: “Fatigue is more than just being tired – it can significantly impair decision-making, motor skills, and alertness. We must move away from viewing fatigue as an individual issue and putting the onus on personal responsibility and instead treat it as a system-level risk that deserves urgent attention.
“Awareness of the risks that staff fatigue poses to patient safety is beginning to grow within healthcare, but our investigation found that understanding remains inconsistent and fragmented. This challenge is further compounded by limited data and the absence of coordinated national oversight – factors that significantly hinder effective risk management.
“As the NHS prepares for reform, the report underscores the need for strong, unified action to protect both patients and healthcare professionals from the risks associated with fatigue.”
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