A new report by the Health Services Safety Investigation Body (HSSIB) has revealed that fatigued NHS healthcare staff pose a significant risk to patient safety, even though this risk is rarely acknowledged.
Looking at the impact of staff fatigue on patient safety, the report found that there is little evidence available to help understand the severity and scale of the problem, apart from some data from surveys. The healthcare sector lacks proper systems to be able to measure, monitor and manage this problem, as fatigue is not routinely captured or considered in patient safety event reporting or learning reviews.
This is a problem as it means that fatigue in healthcare is often misunderstood as a wellbeing concern rather than a critical patient or staff safety risk.
The report highlights how mistaking fatigue as an individual issue, rather than a systemic or culture issue, can create a culture of blame, which prevents staff speaking up when fatigue may have contributed to patient safety incidents out of fear of disciplinary action.
The report found that there is a link between fatigue and preventable patient harm and staff safety incidents, including fatal road accidents post-shift. Fatigue can be caused by a variety of factors, including shift length, lack of breaks, caring responsibilities, and socioeconomic pressures, as well as cultural norms in the NHS as a caring profession, including pride and heroism in working long hours without breaks.
The report concluded with two safety recommendations aimed at developing, reviewing, and improving data capturing measures on fatigue and establishing a consensus definition of fatigue for healthcare.
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.”
