learning from breast screening incidents · consultant in public health and head of sqas - ......
TRANSCRIPT
LEARNING FROM BREAST SCREENING INCIDENTS
DR KHADIDJA BICHBICHE
CONSULTANT IN PUBLIC HEALTH AND HEAD OF SQAS -
LONDON
WHAT IS A SCREENING INCIDENT?
2 NHS Screening e-Learning modules > CPD Screening Incident Management Resource
THE UK NATIONAL SCREENING COMMITTEE IDENTIFIES A SCREENING
INCIDENT AS:
"AN ACTUAL OR POSSIBLE FAILURE AT ANY STAGE IN THE PATHWAY OF THE SCREENING SERVICE WHICH EXPOSES THE PROGRAMME TO
UNKNOWN LEVELS OF RISK THAT SCREENING, ASSESSMENT OR TREATMENT HAVE BEEN INADEQUATE AND CONSEQUENTLY THERE
ARE POSSIBLE SERIOUS IMPLICATIONS FOR THE CLINICAL MANAGEMENT OF PATIENTS."
(June, 2010)
SCREENING PATHWAYS ARE COMPLEX
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LEARNING FROM INCIDENTS
4 NHS Screening e-Learning modules > CPD Screening Incident Management Resource
SCREENING INCIDENTS (APRIL-JUNE 2015)
SCALE- LONDON COMPARED TO NATIONAL
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NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
(25 incidents reported
nationally in Q1 April-
June 2015. None
deemed Serious )
BREAST SCREENING INCIDENTS- NATIONAL DISTRIBUTION
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NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
NATIONAL THEMES - THE MORE COMMON INCIDENTS
7 NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
NATIONAL THEMES- LESS COMMON INCIDENTS
8 NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
9 NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
THEME ADMINISTRATION
CONSEQUENCE • MISSED OR DELAYED
SCREENING • DAMAGE TO PROGRAMME • REPUTATION • CLIENT EXPERIENCES STRESS • POTENTIAL DELAY IN
DIAGNOSIS /TREATMENT
LEARNING
NEED FOR ROBUST MANAGEMENT OF APPOINTMENTS PROCESS SUPPORTED BY FULLY FUNCTIONAL AND VALIDATED SOP/PROTOCOLS IN LINE WITH THE GUIDANCE
REVIEW AND ANALYSIS
10 NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
THEME EQUIPMENT FAILURE
CONSEQUENCE • DELAYS IN PATHWAY • DELAY IN READING • BREACH OF NATIONAL
TARGETS • POTENTIAL FOR IMAGES
TO BE MISINTERPRETED
LEARNING
BUSINESS IMPACT ASSESSMENT (BIA) TO INCLUDE THE POTENTIAL THAT PACS FAILURE MAY OCCUR. AN INTERIM SOLUTION TO PULL IMAGES SHOULD BE INCLUDED IN THE BIA
REVIEW AND ANALYSIS
REVIEW AND ANALYSIS
11 NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
THEME MDT RELATED
LEARNING
• NEED FOR ROBUST PROCESSES TO ENSURE PATHOLOGY SPECIMENS REACH THE CORRECT LABOROTORY FOR PROCESSING
• NEED FOR INFORMATION AVAILABILITY OF ALL TESTS AND RESULTS TO MDT PRIOR TO DECISION MAKING OF RR
• EDUCATION AND TRAINING OF STAFF TO REITERATE THE IMPORTANCE OF ATTENTION TO DETAIL
12 NHS screening programmes (Antenatal, Newborn and Young Person & Adult including cancer screening) incidents
reported Q1 April- June 2015
KEY LEARNINGS FROM VARIOUS INCIDENT THEMES
AND FINALLY…
WHAT CAN YOU DO TO IMPLEMENT THE LEARNINGS?
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