Frontline workers are very rarely to blame in the vast majority of problems states an independent report into patient safety in the NHS.
The Berwick report was carried out by independent US safety expert, Professor Don Berwick, to advise the NHS into how to prevent patients being harmed while receiving healthcare. It was commissioned by the government after the breakdown of care in the Mid Staffordshire Foundation Trust.
The report has identified that NHS staff should not be held accountable for many cases, it is the systems and constraints they face that lead to patient safety problems.
Staff also need to recognise that there should be better regulation in detecting failings earlier and taking appropriate action. Tools should be put into place so that individual voices can be heard to prevent further patient safety problems.
However, while the report has highlighted that understaffing has been an issue, the report does not support calls for a national minimum staffing level, instead urging that trusts should be able to examine their staffing levels each day.
Peter Carter, the general secretary of the RCN, said: ‘This is the latest in a series of thorough reports by well respected experts which is urging a focus on having the right number of registered nurses and support staff to care for patients. The growing body of evidence shows that the only way to ensure patient safety is to have adequate staff with the right skills and the opportunity to learn and develop on an ongoing basis.
‘We're particularly pleased to see the focus on creating and supporting a culture of learning, to motivate staff, and making sure leaders are visible and approachable and understand the realities of patient care. Ward sisters have a vital role to play in that visibility; giving support, guidance and supervision to their teams to ensure an open culture and a high performing ward.'
Professor Berwick also wrote a letter to clinicians thanking them for their work and insisting that the NHS should be a ‘learning organisation' in order to bring about the best care for patients.