Out-of-hours GPs are immersed in a culture of "avoiding blame" and must take responsibility for failings.
A lack of incident reporting in out-of-hours settings and other primary care organisations shows GPs are reluctant to admit their mistakes, which could potentially lead to avoidable deaths.
The NHS Alliance, backed by the Department of Health (DH) and the Care Quality Commission (CQC), has called for a new anonymous reporting system to allow GPs to learn from their mistakes without fear of blame.
Following the 'unlawful killing' of David Gray in 2008, in which German GP Daniel Ubani administered a fatal overdose of the painkiller diamorphine, out-of-hours GP services have come under heavy scrutiny.
The scandal led to reviews by the DH and the CQC, highlighting how "slow" GPs are to learn from mistakes – both within organisations and across the wider urgent care system.
A pilot of the anonymous reporting tool using 10 out-of-hours service providers showed the need for linked reporting with pathology services and A&E.
It was found there may also be "considerable learning" to be had by sharing less serious incidents or 'near miss' experiences.
"We believe that a sharing of problems, ideas and policies could lead to the making of joint recommendations on the management of certain out-of-hours 'knots', which may, in due course lead to the setting of agreed standards, in what has hitherto been a very varied and disjointed market," said Dr Kathy Ryan, Chair of the Clinical Panel – a supporting network included in the pilot.
It is said the anonymous reporting system would give GPs "cultural permission" to admit "they occasionally mess up".
Rick Stern, Urgent Care Lead for the NHS Alliance, said rules and guidelines are not enough to overturn the NHS culture of "avoiding blame" in out-of-hours services.
"Creating a system that allows people to learn from their mistakes and share their learning with others, rather than only being blamed by what went wrong, is key if we are to improve patients' safety and out-of-hours services," he said.