Patient safety 'must be top priority in NHS'
Patient safety must become the top priority in the NHS in England, according to a major review.
The report by Prof Don Berwick, US President Barack Obama's former health adviser, said problems existed "throughout" the system.
But he added the NHS remained an "international gem" and could be the safest system in the world.
He said a series of cultural changes were needed, but also recommended criminal sanctions in extreme cases.
Prof Berwick said charges should be applied where organisations misled regulators or in the rare cases in which "wilful or reckless neglect" by organisations or individuals had harmed patients.
Chatting at the bedside to a patient, a nurse updates the information in their electronic record via a tablet computer. This is the raw material driving improvements in safety at the Queen Elizabeth Hospital in Birmingham, writes Branwen Jeffreys.
The information from that individual record is translated into day-by-day monitoring of quality. For the nurse in charge of a ward that means they can get information updated at midnight each day on how they are doing on delivering safe care.
It counts infections, patients falling on wards, how many are assessed for the risk of clots and the many thousands of decisions made about medicines.
Mobile computer units on each ward translate that into colour-coded charts that give an update at a glance. The data shows what each doctor prescribes, and what drugs each nurse is giving to individual patients.
The aim, says the trust, is to make every error count. Teams are held to account if they're lagging behind and new quality targets are set constantly. But perhaps the most powerful tool is transparency - each ward can see how they're doing compared to the others.
But he stopped short of calling for a duty of candour, which would compel the NHS to inform patients of any errors made in their care.
He said this would be too bureaucratic and should instead be applied only after serious incidents had happened.
He also resisted calls for set minimum staffing ratios, but said trusts should be keeping a close eye on staffing levels to make sure patient care was not suffering.
Prof Berwick was asked by ministers to conduct the review after the public inquiry into the neglect and abuse at Stafford Hospital concluded the NHS had "betrayed" the public by putting corporate self-interest before safety.More co-operation
Many of his recommendations in the 45-page report focus on the creation of a new culture of openness and transparency.
He said all information - apart from personal details - should be made publicly available.
Prof Berwick also called for more co-operation between the various regulators and management bodies in the NHS.
He said the current system was bewildering in its complexity and there should be a review by 2017 to make sure the different bodies were working together on the issue.
And he said staff must be given good support and training to help make sure they took pride and joy in their work.
He said where honest errors were made there should be a culture of "no blame".
If all this was done, Prof Berwick said he could see no reason why the NHS could not become the "safest in the world".
But he said too often in complex organisations like health systems with targets to hit and budgets to manage priorities could become skewed.
Who is Prof Don Berwick?
Prof Don Berwick has won global recognition for his work on making hospitals safer. His mantra has been that health systems should not see mistakes as inevitable - and instead should learn from businesses such as the airline industry which advocate zero harm.
The Institute for Healthcare Improvement, which he co-founded in Cambridge, Massachusetts, has worked with healthcare systems around the world.
Prof Berwick described the NHS as "one of the astounding human endeavours of modern times" in a speech marking its 60th anniversary in 2008.
His admiration for the publicly funded and provided NHS led to criticism from Republicans when President Obama appointed him Administrator of Medicare and Medicaid. He stood down after a year, shortly before facing a nomination hearing.
"In any organisation, mistakes will happen and problems will arise, but we shouldn't accept harm to patients as inevitable," he said.
"By introducing an even more transparent culture, one where mistakes are learnt from, where the wonderful staff of the NHS are supported to learn and grow, the NHS will see real and lasting change."
The government will respond to the review in detail at a later date.
But Health Secretary Jeremy Hunt said he would be seeking to act on the recommendations.
"This is a fantastic report. For too long, patient safety and compassionate care have become secondary concerns in parts of the NHS and this has to change."
Royal College of Nursing chief executive Peter Carter said: "Patient safety has to be at the heart of the daily work and culture of everyone in the NHS, from the government and chief executives to porters, cleaners and every clinician.
"For this to happen we need to see a greater transparency, a no-blame culture where individuals can speak up and challenge any problems which threaten the quality or safety of patient care and feel that their concerns are being heard."
But Roger Goss, co-director of Patient Concern, said action was needed.
"Like all reports of NHS's failings, it sounds as if it is long on what is needed but short on how its recommendations will be made to happen."