Patient safety must become the top priority in the NHS in England, according to a major review.
The report by Prof Don Berwick, US President Barack Obama’s former health adviser, said problems existed “throughout” the system.
But he added the NHS remained an “international gem” and could be the safest system in the world.
He said a series of cultural changes were needed, but also recommended criminal sanctions in extreme cases.
Prof Berwick said charges should be applied where organisations misled regulators or in the rare cases in which “wilful or reckless neglect” by organisations or individuals had harmed patients.
But he stopped short of calling for a duty of candour, which would compel the NHS to inform patients of any errors made in their care.
He said this would be too bureaucratic and should instead be applied only after serious incidents had happened.
He also resisted calls for set minimum staffing ratios, but said trusts should be keeping a close eye on staffing levels to make sure patient care was not suffering.
Prof Berwick was asked by ministers to conduct the review after the public inquiry into the neglect and abuse at Stafford Hospital concluded the NHS had “betrayed” the public by putting corporate self-interest before safety.
Many of his recommendations in the 45-page report focus on the creation of a new culture of openness and transparency.
He said all information – apart from personal details – should be made publicly available.
Prof Berwick also called for more co-operation between the various regulators and management bodies in the NHS.
He said the current system was bewildering in its complexity and there should be a review by 2017 to make sure the different bodies were working together on the issue.
And he said staff must be given good support and training to help make sure they took pride and joy in their work.
He said where honest errors were made there should be a culture of “no blame”.
If all this was done, Prof Berwick said he could see no reason why the NHS could not become the “safest in the world”.