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.