5. incidents review
TRANSCRIPT
Incidents Review: Sharing and
Learning from Common Themes
London Local Screening Coordinators & Heads of Midwifery
Forum
1 July 2016
Michelle Onslow
Senior QA Advisor, London Screening Quality Assurance Service.
Contents:
• Overview of incidents across London
in the last 6 months
• Review of the main themes and
lessons
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3
NCL 37
NEL 49
NWL 13
SEL 21
SWL 16
Total London ANNB Incidents 1.12.2015 - 31.5.2016
NCL
NEL
NWL
SEL
SWL
Total = 136
Incidents Review: Themes and Learning LCO & HoM forum - 1 July 2016
London incidents by programme
11
11
8
2
102
2
FASP
IDP
SCT
NHSP
NBS
NIPE
4
Incidents Review: Themes and Learning LCO & HoM forum - 1 July 2016
Serious Incidents • 6 serious incidents reported in the
timeframe
• 3 NBS, 1 FASP and 2 IDS incidents
• Incomplete antenatal screening bloods
for 50 women found at KPI data
collection
• Missed down’s syndrome screening –
affected baby
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Serious Incidents
• Diagnosis of SCD at 10 years of age –
unknown screening status
• Lab – discrepant reporting of HIV & Hep B
positive ANNB screening result
• Lab – delayed repeat request for CF
inconclusive result – delayed entry into care
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Themes – Infectious diseases
• Missed/delayed Screens: Lack of failsafe
Failsafe in place but not monitored
Lack of escalation
• Delayed referral into treatment
• Delay or missed vaccination or HBIG Late bookers, transfer in labour, baby on HDU with
Mum
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Themes: SCT
• Missed/delayed screening – some
resulting in delayed diagnosis of at risk
couples
• Lab – delayed reporting of results,
ambiguous wording of results – national
standards not followed.
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Themes: FASP
• Missed screens – more on this later!
• Of the 11 FASP incidents reported for this
time frame 9 of them are missed
screening incidents affecting at least 20
women
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Themes: NBS • Delayed screening due to no receipt of discharge
paperwork
• Midwives repeating NBS samples without knowing the
reason why
• Family visited for a repeat NBS screen after the baby
had passed away
• Incorrect entry at birth notifications not corrected
appropriately
• Northgate ping pong
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Themes: NHSP
• Audiology referral was cancelled as a record was
deactivated in error
• Premature baby was screened and diagnosed
with a PCHI but was too young to be screened
• No incidents reported in London where families of
deceased babies were contacted – huge
success!
11
Incidents Review: Themes and Learning LCO & HoM forum - 1 July 2016
Themes - NIPE • Missed or delayed screens – reduction in the
numbers reported as incidents
• One late diagnosis of congenital dislocation of
the hips – met the screening criteria for a hip
ultrasound but not organised before discharge,
picked up by GP at second NIPE that took place
at 12 week.
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Key Messages 1) Failsafe’s – essential to reduce the risk of missed screens; they only work if
they are monitored regularly and missing results are escalated
2) They must also be in place to ensure that women and babies are referred
into care and/or receive the treatment they require – it’s the point of
screening
3) Screening incidents in labs should be reported too – please let us know if
you know. Don’t recall women before seeking QA advice!
4) NBS samples shouldn’t be repeated without knowing the reason – ideally
write the reason on the card
5) Discharge details – important to know they reached the receiving hospital
6) Bereavement checklists – is updating Northgate included?
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Thank you