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Hywel Dda UHB - Multidisciplinary Maternity and Neonatal Risk and Governance Team: Changing Workplace Culture Around Adverse Events in Maternity and Neonatal Care

The team identified evidence of poor psychological safety, resulting in low incident reporting rates – as well as staff across maternity and neonatal services who were disengaged from learning. The team co-produced a strategic and sustainable programme which focused on system learning rather than individual apportioning of blame. This resulted in increased incident reporting, improved staff satisfaction, a positive impact on safety culture and improved outcomes for women and their babies, with a significant reduction in babies born with APGAR<7 and the stillbirth rate. The judges found the project commendable, showing improvements in patient outcomes and staff satisfaction, with ongoing potential for positive outcomes.

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