WAQ76036 (e) Wedi’i gyflwyno ar 22/02/2018

Pa ymchwiliad wedi'u cynnal i nifer y digwyddiadau diogelwch cleifion a nodwyd fel rhai ddifrifol neu a ddaeth i ben mewn marwolaeth ym Mwrdd Iechyd Prifysgol Betsi Cadwaladr rhwng 1 Chwefror 2017 a 31 Ionawr 2018, gan mai dyma'r uchaf yng Nghymru, a pha fesurau a gaiff eu cymryd i atal digwyddiadau o'r fath?

Wedi'i ateb gan Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol | Wedi'i ateb ar 05/03/2018

Every year many thousands of patients receive high quality, safe and effective treatment but in a modern, increasingly complex health system incidents will still happen.  Where this is the case we expect every NHS organisation, including Betsi Cadwaladr University Health Board (BCUHB) to report every incident, in a timely manner to the National Reporting and Learning System (NRLS) and to investigate it thoroughly so root causes are identified for improvement. 

 

This reporting process demands a culture of openness and learning to prevent incidents recurring.  We welcome a continued increase in reporting across Wales, as we know from extensive research that high reporting is a positive indicator of an open and supportive patient safety culture.  During this 12 month period a total of 95,347 incidents were reported but of these 61,418 resulted in no harm. These ‘near misses’ represent a huge opportunity for learning to prevent future incidents and demonstrate why it’s important to have an open and transparent reporting system.

 

All organisations are required to investigate all reported incidents and determine how the learning will be applied across their areas. More detailed information relating to the cause of these incidents and the associated levels of harm will be held at a local level.

 

Where appropriate Welsh Government may also issue a patient safety notice or alert to ensure wider learning across the whole of the NHS in Wales.

   

Comparisons should not be made across health boards as each has its own demographic and population size.  Based on the latest NRLS data the assumption cannot be made that BCUHB has the highest number of deaths and severe incidents, it just means it has the highest number of reports of these incidents, which demonstrates an open and transparent culture in this large organisation, which is to be welcomed.