Safety World - Recognise the need for systemic change

NHS staff should be supported to learn from mistakes and patients and caregivers should be foremost in an attempt to make the NHS a world leader in patient safety world , an independent report said today. Professor Don Berwick , internationally renowned expert in the field of patient safety, was invited by the Prime Minister to carry out the review after the publication of the report of Francis in the distribution of care between hospitals in Staffordshire .

The report, led by Professor Don Berwick , after five months of intensive work to review safety lessons NHS patient health care and other industrial facilities worldwide safety world.

Its four main conclusions are: safety world

The quality of patient care , safety , including patients, should be paramount
Patients and caregivers should be empowered , engaged and heard
Staff should be supported to develop and improve what they do
There should be full transparency of data to improve care
The report's recommendations include: safety world

The NHS must adopt a culture of learning
can not come from the regulation , but "numerous , consistent and repeated " messages to staff so that the objectives and incentives are clear and in the best interest of patients
Staffing levels should be adequate, based on test safety world
The report echoes the opinion Keogh say that staffing levels can not be dictated from the
center , but local councils and leaders must take responsibility for ensuring that clinical areas

adequately staffed

Building relationships with patients and front-line
Leaders have firsthand knowledge of the reality of the system and the patient's voice should be heard and listened to at any time. Complaints systems should be continually reviewed and improved
Transparency must be complete , fast and unambiguous. No single measure for safety world

The NHS should continue using mortality indicators to detect potentially serious problems. However, safety world these indicators are a " smoke detector " and should not be used to generate league tables

Control and regulation should be clear, A full and independent review of the structures and the regulatory system should be completed by the end of 2017 , after the recent changes have been in operation for three years safety world. New offenses should be established

about recklessness or willful neglect or ill-treatment by organizations or individuals and health care organizations that have relevant information or hinder . However, the report notes that the use of criminal sanctions should be extremely rare and unintentional errors should not be criminalized safety world.