15.45 p.m. 16.30 p.m. - rca nhse
TRANSCRIPT
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