There’s been a lot of interesting discussion online following the release of Don Berwick’s report to the NHS, A promise to learn – a commitment to act. Critics of the report say that, while it provides sound observations about the complexities of healthcare in the NHS and worldwide, the report lacks practical advice for how the NHS can move forward, both efficiently and effectively, after the tragedies that ensued at Mid-Staffordshire. But perhaps the intent of its message is not to provide the NHS with a step-by-step list of objectives for how to implement specific system changes but to articulate the grandeur of the undertaking the NHS (or any healthcare system) must whole heartedly embrace: to nurture and support a “learning culture.” 

Loud and clear in the report is the message that patient safety is everyone’s responsibility. No one person, or leader, or unit is to blame when our efforts to help the sick go wrong. Everyone has an important role to play in making healthcare safer and with a cohesive, transparent culture we can reach our goal to achieve optimal patient safety together.

My own reaction to Berwick’s report is a feeling of purpose and empowerment, knowing that in British Columbia we have a system in place that has become a vital component in our enduring quest to deliver the safest and highest quality healthcare possible. From the beginning, BC PSLS was envisioned as a means of fostering a healthcare culture that would encourage healthcare providers to identify safety issues, and leaders to learn how to prevent them from happening again. You – those on the front line, educators, leaders, and others – who have embraced BC PSLS and use it to improve safety for our patients and families, are helping create and nurture a culture of safety, and we –  all of us at BC PSLS Central Office – thank you for all you do to make healthcare safer in our province.

Berwick et al.’s report is exceptionally articulate with numerous key messages worthy of sharing. Here are a few of my favorites:

  • The capability to measure and continually improve the quality of patient care needs to be taught and learned or it will not exist.
  • The most valuable sources of information are the reports and voices of patients, carers and staff.
  • Patient safety is the keystone dimension of quality. The pursuit of continually improving safety should permeate every action and level in the [organization].
  • Patient safety cannot be improved without active interrogation of information that is generated primarily for learning, not punishment, and is for use primarily at the front line.
  • Because human error is normal and, by definition, is unintended, well-intentioned people who make errors or are involved in systems that have failed around them need to be supported, not punished, so they will report their mistakes and the system defects they observe, such that all can learn from them.
  • I urge you to focus on the culture that you want to nurture: buoyant, curious, sharing, open-minded, and ambitious to do even better for patients, carers, communities, and staff pride and joy. If you read our recommendations carefully, and act on them, I believe that you will have set your compass right.

You can read the full report here.


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