The number of "never events" at the largest health board in Wales more than doubled in a year, according to its latest report.
Never events are serious, largely preventable patient safety incidents that should not happen if national safety guidance is followed.
Betsi Cadwaladr University Health Board (BCUHB) logged 11 never events in 2025-26, increasing by six compared with the previous year.
The health board with the second-highest total recorded seven incidents.
The report said the level of "avoidable harm" remained a "serious concern" for the health board, which is "committed to ensuring ongoing improvements".
Examples of never events can include operating on the wrong part of the body, leaving surgical instruments inside a patient after an operation or administering medication by the wrong route.
The report said investigations focused on identifying system and process failures rather than individual blame, so "meaningful learning" can be achieved.
"Where required, immediate actions are taken to protect patient safety while investigations are completed," the report added.
It said the board had a "clear commitment to strengthening systems and learning to support a continued reduction in never events" and hopes to achieve zero never events in 2026-27 and future years.
Source: BBC News, 28 July 2026
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