NHS staff fatigue factor in patient harm and deserves urgent attention
Medication errors, impaired decision-making, reduced attention or vigilance, and rude or disrespectful behaviour by workers are the most common consequences, its report said.
The patient safety body warned that fatigue 'contributes directly and indirectly to patient harm' but said there is 'little evidence' to help understand the size and scale of the risk as it called for a review to help capture the related data.
Fatigue is more than just being tired - it can significantly impair decision-making, motor skills and alertness Saskia Fursland, HSSIB
Examples of patient safety issues heard by HSSIB investigators included one staff member who failed to perform a pregnancy scan accurately, which they felt contributed to safety issues for the mother and baby at birth.
The probe heard the member of staff had a health condition and had not slept well, but this was worsened by staffing issues and a high workload.
Fatigue 'was not considered as part of the safety event learning and that they were not involved in the investigation', according to the worker.
Another example was of a young patient given the wrong chemotherapy infusion.
The HSSIB heard the two members of staff who checked the medication were almost nine hours into a 12-and-a-half-hour shift and a trust investigation found that fatigue was 'likely to have been a factor'.
Staff fatigue is not routinely captured as part of patient safety event reporting or routinely considered as part of patient safety event learning, the HSSIB report said.
It also highlights that there are no specific questions about fatigue in the NHS Staff Survey, which includes responses from more than 700,000 workers.
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 Saskia Fursland, HSSIB
However, in the 2024 poll, two in five staff reported feeling worn out by the end of a shift, while one in five said every waking hour is tiring.
The issue is also impacting staff safety, with some exhausted staff involved in fatal car accidents or near misses while driving home from a shift, the HSSIB said.
The report claims staff are fatigued for a variety of reasons, such as excessive workloads, long shifts, not enough rest time and inadequate breaks.
There were also personal factors such as menopause, pregnancy and religious practices, as well as lower-paid staff picking up extra shifts or an additional job to make ends meet.
The HSSIB warned fatigue is perceived by trusts and staff as an 'individual risk, with limited organisational accountability', leading to a 'blame culture'.
Saskia Fursland, senior safety investigator at the HSSIB, said: '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.'
The probe also found that there are 'barriers' to understanding the risks posed by fatigue, including the 'norms' around working long hours in the health service.
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 Saskia Fursland, HSSIB
It said some staff 'spoke of deeply entrenched and historical beliefs where working long hours was seen as a 'badge of pride', particularly among senior staff'.
Others told HSSIB investigators 'that it was seen positively for staff to stay beyond their contract hours and that it was sometimes actively encouraged by healthcare organisations'.
Organisations also have 'limited ability' to address these risks amid constraints to the workforce and finances, the report added.
The HSSIB recommends that NHS England and the Department of Health and Social Care should review processes to help capture data related to staff fatigue in order to understand risks and inform the development of a future strategy to tackle the issue.
Ms Fursland added: '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 co-ordinated 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.'
Steps to protect and enhance staff wellbeing and reduce the risk of fatigue must be a priority at every level Saffron Cordery, NHS Providers
Responding to the report, Patricia Marquis, executive director of the Royal College of England, said it 'lays bare the daily reality for nursing staff'.
'They are overstretched, understaffed and regularly work beyond their hours caring for too many patients,' she added.
'This drives dangerous levels of fatigue which not only harms patients but also follows staff home, with sometimes devastating consequences.
'Nursing fatigue is deadly and in health and care services should be treated as a public safety emergency.'
An NHS spokesperson said: 'NHS staff are working incredibly hard to meet rising demand for care, but we know that this can take a toll on their wellbeing and we're committed to tackling burnout by ensuring staff get the support they need, so they can continue to provide safe and effective care for patients.
'Staff should always feel confident to report patient safety concerns, including those that are linked to fatigue, and we will work with local NHS systems to address any issues – while there is more we could and should do, the NHS is offering more flexible working options than ever before, and there is a range of mental health support available for staff, including access to wellbeing resources.'
Saffron Cordery, interim chief executive of NHS Providers, added: 'Steps to protect and enhance staff wellbeing and reduce the risk of fatigue must be a priority at every level, and HSSIB is right to highlight the potential risks associated with staff fatigue in implementing national initiatives on workforce challenges and care delays.'
A Department of Health and Social Care spokesperson said the Government 'inherited a broken NHS with an overworked, demoralised workforce' and the report 'highlights the profound consequences this can have for patients and staff alike'.
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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 Saskia Fursland, HSSIB However, in the 2024 poll, two in five staff reported feeling worn out by the end of a shift, while one in five said every waking hour is tiring. The issue is also impacting staff safety, with some exhausted staff involved in fatal car accidents or near misses while driving home from a shift, the HSSIB said. The report claims staff are fatigued for a variety of reasons, such as excessive workloads, long shifts, not enough rest time and inadequate breaks. There were also personal factors such as menopause, pregnancy and religious practices, as well as lower-paid staff picking up extra shifts or an additional job to make ends meet. The HSSIB warned fatigue is perceived by trusts and staff as an 'individual risk, with limited organisational accountability', leading to a 'blame culture'. Saskia Fursland, senior safety investigator at the HSSIB, said: '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.' The probe also found that there are 'barriers' to understanding the risks posed by fatigue, including the 'norms' around working long hours in the health service. 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 Saskia Fursland, HSSIB It said some staff 'spoke of deeply entrenched and historical beliefs where working long hours was seen as a 'badge of pride', particularly among senior staff'. Others told HSSIB investigators 'that it was seen positively for staff to stay beyond their contract hours and that it was sometimes actively encouraged by healthcare organisations'. Organisations also have 'limited ability' to address these risks amid constraints to the workforce and finances, the report added. The HSSIB recommends that NHS England and the Department of Health and Social Care should review processes to help capture data related to staff fatigue in order to understand risks and inform the development of a future strategy to tackle the issue. Ms Fursland added: '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 co-ordinated 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.' Steps to protect and enhance staff wellbeing and reduce the risk of fatigue must be a priority at every level Saffron Cordery, NHS Providers Responding to the report, Patricia Marquis, executive director of the Royal College of England, said it 'lays bare the daily reality for nursing staff'. 'They are overstretched, understaffed and regularly work beyond their hours caring for too many patients,' she added. 'This drives dangerous levels of fatigue which not only harms patients but also follows staff home, with sometimes devastating consequences. 'Nursing fatigue is deadly and in health and care services should be treated as a public safety emergency.' An NHS spokesperson said: 'NHS staff are working incredibly hard to meet rising demand for care, but we know that this can take a toll on their wellbeing and we're committed to tackling burnout by ensuring staff get the support they need, so they can continue to provide safe and effective care for patients. 'Staff should always feel confident to report patient safety concerns, including those that are linked to fatigue, and we will work with local NHS systems to address any issues – while there is more we could and should do, the NHS is offering more flexible working options than ever before, and there is a range of mental health support available for staff, including access to wellbeing resources.' 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