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Berwick report due on 'zero-harm' culture for NHS

A major review aimed at introducing a “zero-harm culture” in the NHS is set to be published.

Professor Don Berwick, a world expert in patient safety, was tasked by Prime Minister David Cameron earlier this year with conducting a root-and-branch safety review of English hospitals.

He believes the scandal at Mid Staffordshire Foundation Trust, where between 400 and 1,200 more people died than would normally have been expected, should act as a catalyst to drive improvements in the health service.

A former adviser to US president Barack Obama, Prof Berwick has said he believes the NHS could offer the safest healthcare in the world.

The review, involving a team of experts from the UK and US, has examined why some patients needlessly suffer or die in hospital because of errors.

One basic element of creating a zero-harm culture includes using checklists before surgery and asking patients to give their name before any treatment is given.

Prof Berwick founded the Institute for Healthcare Improvement in Boston which conducted an earlier internal review for the NHS.

Released under a Freedom of Information request in 2010, it found a “shame and blame” culture in the NHS which was preventing care from improving.

In March, Prof Berwick said he would recommend how the NHS could take “serious and profound” action to improve safety.

He said: “Assuring patient safety and high quality care is never automatic. It requires the constant attention of leaders and continual support to the workforce.

“I have read, and been deeply affected by, the harrowing personal stories of individuals and families who were so badly injured when this commitment flagged at Mid Staffordshire Hospitals.

“Our group will do whatever it can to recommend how the NHS in England take serious and profound action, learning from this tragedy to make patient care and treatment as safe as it can possibly be, and ever safer.

“Indeed, there is no reason why English healthcare cannot aspire to be and become the safest healthcare in the world.”

Mid Staffordshire was at the centre of a public inquiry into Stafford Hospital, where hundreds of patients were routinely neglected.

Led by Robert Francis QC, the inquiry reported earlier this year, highlighting the “appalling and unnecessary suffering of hundreds of people”.

Some patients were left lying in their own faeces for days, forced to drink water from flower vases or given the wrong medication.

The findings prompted a separate review, led by NHS medical director Professor Sir Bruce Keogh, of 14 NHS hospitals in England with high death rates.

As a result of that review, 11 hospitals were placed in special measures for “fundamental breaches of care”.

 

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