Public Health England leads the NHS Screening Programmes

CST and Screening Technician Workshop – 10 November 2016-What can we learn from reported AAA screening incidents?Paola Beresh, QA Advisor, SQAS (London)

Reported London AAA incidents (December 2014 to October 2016)

Learning from AAA incidents2.

AVEs - 8

SI- 1

SSIs - 2

Non Screening - 2

AVE - 8

SI - 1

SSI - 2

Non Screening - 2

SI - 1

Non Screening Incidents - 4

No Concern - No Further Action Problem Still Suspected - Further Investigation RequiredProblem Confirmed - To be managed InternallySSIs (internal and multi-disciplinary)SIs

No concern - 6

Managed Internally - 9

SSI - 17

SI -1

Still Suspected - 2

Classification

Source: PHE incident Trackwise database and submitted SIAFs

Reported London AAA incidents (December 2014 to October 2016)

AAASP1 AAASP2 AAASP3 AAASP4 AAASP5012345678

SI ReportedSSI ReportedProblem Confirmed - To be managed internallyProblem Still Suspected - Further Investigation RequiredNo Concern - No further action

7 SSI1 Mgd Internally2 Still Suspected2 No Concern

3 SSI2 Managed Internally

3. Learning from Incidents

3 SSI 1 Managed Internally

1 SI2 SSI2 Managed Internally2 No Concern

2 SSI3 Managed Internally2 No Concern

Classification by screening service

OpenClosed

Closed – 20

Open – 15

4. Learning form Incidents

Reported London AAA incidents (December 2014 to October 2016) Incident status

Learning from Incidents

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 270

100

200

300

400

500

600

Days taken to complete each stage of an incident

Days

A = Between Date Incident Identified and SIAF Received

B= Between SIAF received and Section 2 completed

C= Between SIAF received and Sec-tion 3 received D= Between Incident Identified

and Closure

Timescales for incident management stages

5.

Themes- incident grouped by similarities

1 5 2 1 1 2 1 2 1 1 4 1

1 5 21

1021

690

6212 2 Unknown

0 21 13

Number of incidents No of People Affected

Unknown

6. Learning from Incidents

Lessons Learnt

7 Learnings from Incidents

Theme Lessons Learnt

Ultrasound Machines not serviced

Robust process to monitor maintenance of equipment.Closer monitoring of contracts when up for renewal

Delayed Printing of GP result letters

Protocol for letter administration with a failsafe spreadsheet to robustly monitor numbers of letters printed.

GP Unregistered Patients Issue a letter to patients when they unregister from a GP alerting them to the fact that they need to register with a GP to be invited for screening

Establish a review period to give GP unregistered patients an opportunity to reregister and be reinvited

Lessons LearntTheme Lessons Learnt

Breach in 8 week referral to surgery due to Hospital Factors

Robust referral and tracking process with clear timescales and duties of the team members outlined.

Medical history checks to be strengthened in assessment clinics.

Appropriate administrative support to track patients post-MDM discussion and flag issues to service directorate

Only NASSP measurements to be included on SMART

8 Learnings from Incidents

9 Learning from Incidents

Patien

t Dea

th

Loss

/ Miss

ing / M

isave

d Imag

es

Result

s Inc

orre

ctly L

ogge

d / W

rong

App

ointm

ent

IG / C

onfid

entia

lity B

reac

h

Unsafe

Scre

ening

Env

ironm

ent

Patien

ts 5 Y

ear S

urve

illanc

e for

AAA of

2.6-

2.9cm

Loca

l Pro

gram

mes U

sing 2

1 Gen

eric

Login

s

Incide

ntal F

inding

Pro

cess

Fail

ure

Proce

ssing

Issu

es w

ith S

uspe

nded

SSPI M

essa

ges (

SI)

1 8 3 2 1 1 1 1 1

1 21 5 1 0 Unknown0 1

326Number of incidents No of People Affected

Reported National AAA incidents (April to October 2016) Themes

10 Learning from Incidents

Reported National AAA incidents (April to October 2016)

Regional breakdown

Region Number of incidents Number of people affected

London 10 111*

South West 4 4”

East of England 3 5

South East 3 14

North East Yorkshire and Humber

4 4*

East Midlands 3 2*

National 2 326

Total 29 466