A total of 65 â€˜never eventsâ€™ have occurred in Welsh hospitals over the last three years, including: surgery on the wrong eye, foreign objects left in patients after surgery, and a hip replacement on the incorrect hip.
The full list can be perused online HERE.
So-called â€˜never eventsâ€™ are incidents which should never happen in a clinical environment, and a worrying 21 were recorded in 2017/18.
It follows 21 in 2016/17 and 23 in 2015/16.
Almost a third of all â€˜never eventsâ€™ over the last three years (20 of 65) were recorded as a result of foreign objects being left in patients after surgical procedures, and there have been a shocking 16 incidences of surgery having been carried out on the wrong site â€“ including an incorrect hip replacement, and surgery in the wrong part of a patientâ€™s spine.
There was also an incident in 2015/16 where a patient fell out of a â€œpoorly constructedâ€� window.
The annual reports show that over the last three years Abertawe Bro Morgannwg and Cardiff and Vale health boards recorded the most never events â€“ 18 and 16, respectively.
They were followed by Betsi Cadwaladr (11), Cwm Taf (8), Aneurin Bevan (7), and Hywel Dda (4) health boards. Last year, Public Health Wales also had once never event. Powys have had none.
Shadow Health Secretary, Angela Burns, said:
â€œThereâ€™s always the potential for human error, but when NHS staff are under immense pressure â€“ dealing with more patients than ever whilst being under-resourced â€“ that margin for error widens.
â€œFortunately, the vast majority of patients receive extremely high levels of compassionate care when encountering the NHS. But these figures remain stubbornly high, and patient safety has been seriously jeopardised on occasions.
These are â€œnever eventsâ€� â€“ incidents that should never have occurred. But they are continuing to happen, leaving lasting, potentially life changing consequences on individuals. This is unacceptable and we need to greater instil a culture of learning, responsibility and accountability in to our NHS as we transform our services for the future.