Anyone in any line of work runs the risk of making a mistake, but a new report suggests that a culture of blame in the NHS makes owning up to these errors and learning from theme extremely difficult.
Health ministers invited President Obama’s former health adviser, Professor Don Berwick, to conduct a review into the NHS in the wake of the damning public inquiry into neglect and abuse at Stafford Hospital, which concluded that staff had betrayed patients by putting corporate self-protection ahead of safety.
Mr Berwick urges the creation of a new “no blame” culture of openness and transparency in the NHS, which is a goal that will require “wide systematic change” to overturn a culture of fear. The latter, the report argues, is “toxic” to staff improvement and patient safety. Mr Berwick added: “Everybody commits errors, and one way to make sure you never know about the error is to start to punish it.”
The review cautions against the cultivation of systems in which NHS personnel are fearful of owning up to errors. Mr Berwick continued: “The report focuses mainly on culture – a learning culture where the NHS becomes a place where everyone’s curious about what’s going on, how they’re doing, how others are doing, what they can do to improve; that cultural piece is important.”
Staff, the report urges, must receive good training and support to help them to take pride in their duties.
Mike Farrar, chief executive of the NHS Confederation, agreed with Mr Berwick’s finding that a “statutory duty of candour” would be counterproductive.