5 Incidents themes; shared learning – Michelle Onslow

Public Health England is responsible for the NHS Screening Programmes

Quality Assurance (London)

Incidents

Themes & Shared Learning

Michelle Onslow, Senior QA Advisor

Sickle Cell and Thalassaemia

• Incidents often identified via NBS screening

• Unexpected affected babies:

needs to be clear that Screening is for common

mutations only

Screening not diagnosis

Some rare mutations may not be detected

• Missed or Delayed Screening:

Failure to identify the cohort

Not following up DNA’s

2 Incident - themes & shared learning

Sickle Cell and Thalassaemia

• Failure to follow up on father results and/or link

results and recognise high risk couples

• Not offering PND when the father is not available

for testing

• Failure to enter care both women and newborns

• Incorrect information on FOQ resulting in an

incorrect report/action required


FASP

• Missed/delayed Screening:

Failure to identify cohort

Lack of failsafe’s – with lab and internally

Failure to follow up DNA

• Failure to complete second trimester screening

for women who have a failed NT or who are too

late for first Trimester screening

• Incorrect data on request form = incorrect risk

calculation


FASP

• Delay or failure in following up screen positive

results – too late for PND

• Undiagnosed fetal anomaly at birth:

Not necessarily an incident if correct pathway was

followed

Not 100% detection rate, screening not diagnosis

Should be reported to provide assurance that the

correct pathway has been followed


Infectious Diseases

• Missed/delayed Screening:

Failure to identify cohort

Lack of failsafe’s – with lab and internally

• Failure to administer HBIG:

Lack of robust processes in place, ordering, storage,

administration

Decision made by clinician due to <HBV DNA Viral

load

National statement released – HBIG should be given

if ANY HBV DNA in pregnancy is high

HBIG and vaccine on midwives exemptions


Infectious Diseases

• Failure to follow up screen positive results:

Delayed entry into care

Delayed treatment and/or missed intervention

Relying on fax of results

Lack of contingency when staff absent

Failure to follow up DNA


NHSP

• Errors associated with implementation of a new

maternity IT system

Upload of birth notification

Information sent to the wrong site

• Delay in screening due to incorrect information

entered i.e. deceased when live birth

• Failure to notify of stillbirth or neonatal death

resulting in inappropriate contact with a family

• Screening by an screener who has not

completed qualification


Newborn Bloodspot

• Largest number of incidents reported of all the

programmes

• Delayed/missed screening:

Failure of discharge information being received by

correct Trust – still relying on fax

Lack of timely transfer of babies that move - Northgate

‘disagreements’ over who has responsibility

Failure to screen ‘movers in’

Delays in independent midwives repeating samples

Units with high NB2 rates have highest number of

incidents


NIPE

• Delayed/missed screening:

Failure to identify cohort –

Sites with SMART not utilising system as a failsafe

Failure to identify ‘outliers’ i.e. babies in HDU with

mother etc.

• Failure/delay in entering care:

No referral done

Referral not followed up

DNA not followed up


General

• New screening incident assessment form:

Please ensure that this is used to report all incidents

and not the old ‘early alert’ form

• Errors on maternity IT system:

Lack of understanding that once the information has

been ‘submitted’ amending on the maternity system is

not sufficient

SOP recommended

Look for evidence of this at QA visit


General

• If patient identifiable information is lost:

For example an NBS sample is taken and sent to the lab but never arrives

This is not always a screening incident but it is an information governance breach and the Trust IG team should be informed

• Don’t forget to consider your Trust communications department:

Essential if women are being contacted and/or recalled

They are likely to want to review letters etc. before they are sent


Healthcare

5 Incidents themes; shared learning – Michelle Onslow