• The Care Quality Commission (CQC) publishes Opening the door to change: NHS safety culture and the need for transformation.
• The report follows a review examining the issues contributing to never events and wider patient safety incidents in NHS trusts.
• It highlights complexity in the current patient safety system leading to confusion and a lack of clarity on which external organisations can provide information and support.
• It also argues that pressures on the health service are leaving little time for staff to implement safety guidance effectively.  

Responding to the report, the head of policy at NHS Providers, Amber Jabbal said:

"Patient safety will always be a top priority for the NHS and Care Quality Commission (CQC) make clear that NHS staff are committed to ensuring that patients are kept as safe as possible.

Patient safety will always be a top priority for the NHS and Care Quality Commission make clear that NHS staff are committed to ensuring that patients are kept as safe as possible.

   

"However, CQC also found that funding, rising demand and workforce challenges make it difficult to learn from incidents and make changes effectively amid so many competing priorities, and that the current NHS approach to patient safety improvement adds confusion on top of these pressures.

"We very much welcome the report and are supporting the development of a national patient safety strategy. CQC have made recommendations that will bring much-needed clarity, consistency and alignment to patient safety efforts across the NHS. It is vital that they are supported as a priority, with all NHS organisations and staff given the training, expertise and resources needed to fully embed an effective safety culture, underpinned by a new coordinated national long term patient safety strategy. Organisations must be able to respond effectively when staff raise concerns about risk and harm in NHS care, to help reduce the risk of further patient safety incidents."