Institute for Healthcare Improvement chair Don Berwick has called for honesty, forgiveness and teamwork among healthcare professionals to improve patient safety, adding that such improvements do not have to be costly.
Speaking at the Patient Safety Congress, Mr Berwick said the natural instinct to blame the doctor, nurse, chief executive or even the patient had to be overcome. The problem was not that people did not try hard enough or care enough.
Ensuring patient safety required a culture in which lessons could be learned and practices revised, he said.
But he warned against excessive measurement, stressing that the key aim was change and measurement without redesign only served to demoralise people.
Mr Berwick also warned against assuming that safety was costly. He said experience from organisations that dealt with safety well suggested that it could help reduce costs and increase staff efficiency.
Summing up, he said patient safety should no more be seen as a programme for the NHS than breathing should be seen as a programme for human beings. Instead, leadership was needed to ensure it was important to everyone every day.
To read about Gordon Brown's speech at the congress, click here
More on patient safety from HSJ