Patients are being put at risk because the NHS has not fully embraced a culture of patient safety, the chief medical officer says.
Some hospitals have been slow to comply with guidance, Sir Liam says
Sir Liam Donaldson's annual report revealed hospitals were slow to comply with patient safety alerts - guidance to help avoid serious mistakes.
Some hospitals were also found to have said they had complied with the advice when they had not.
He said NHS trusts should be penalised for not complying with guidance.
Sir Liam recommended this could be done through the Healthcare Commission taking non-compliance into account during inspections.
SIR LIAM'S KEY POINTS
Patient safety - Hospitals must become quicker to respond to safety alerts, and non-compliance should be taken into account during official inspections
Gastroschisis - More research must be carried out into the causes of gastroschisis, a rare but increasingly prevalent condition which affects newborns, to help prevent it
Lung disorders - National service framework for chronic obstructive pulmonary disease to rectify the patchy services across the country
Hospitals should also be made to publicise whether they to comply with the safety alerts.
Sir Liam said the findings showed that the safety culture in the NHS was not yet focused or organised enough to reduce a potentially fatal risk to patients quickly enough.
"It is clear the culture of some NHS organisations needs to change.
"It is not enough to be aware of the problem of improving patient safety not to report adverse events when they occur
"When alerts are issued, there needs to be commitment from the very top of the organisation to initiate immediate action to address the identified risk, to ensure that all staff are properly and consistently informed."
Sir Liam highlighted the reaction to one patient safety alert on intrathecal chemotherapy - injections into the spine.
Patients can die if the wrong drug is injected into the spine, particularly the drug vincristine, which is commonly given intravenously as part of the same course of treatment.
The death of teenager Wayne Jowett in Nottingham after such an error in 2001 focused attention on the problem.
Sir Liam's annual report said that after guidance on intrathecal chemotherapy was launched in November 2001, NHS trusts had to complete a checklist confirming compliance with the advice by the end of December 2001.
By March 2002, a fifth of NHS trusts remained non-compliant and it was not until summer 2003 that full compliance was achieved.
And an independent review last year found that three trusts, which claimed to have been compliant, were not.
Patients Association chairman Michael Summers said the report's findings were "disturbing".
"There are instances where the system falls down and trusts are slow to react.
"We are also concerned some are not being honest about complying. All this affects how safe patients feel."
A spokeswoman for the NHS Confederation, which represents health service managers, said it was important to remember - as Sir Liam had pointed out - that the NHS was leading the way with improving patient safety.
But she added: "Clearly more work needs to be done to minimise unnecessary risks to patients."
Sir Liam's report - his fourth annual review of public health - also called for a national service framework for chronic obstructive pulmonary disease, an umbrella term for a number of chronic lung disorders which cause 30,000 deaths a year.
And he called for more research into the causes gastroschisis, which occurs in newborn babies when the abdomen wall does not develop and the intestines protrude.