This report highlights the main problems affecting patient safety in the NHS and makes recommendations to address them.
It says that the health system must:
recognise with clarity and courage the need for wide systemic change
abandon blame as a tool and trust the goodwill and good intentions of the staff
reassert the primacy of working with patients and carers to achieve health care goals
use quantitative targets with caution - they should never displace the primary goal of better care
recognise that transparency is essential and expect and insist on it
ensure that responsibility for functions related to safety and improvement are established clearly and simply
give NHS staff career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning
make sure pride and joy in work, not fear, infuse the NHS
Professor Don Berwick, an international expert in patient safety, was asked by the Prime Minister to carry out the review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.