15.45 p.m. 16.30 p.m. learning from incidents

1. 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)

2. Reported LondonAAAincidents (December 2014 to
October 2016)
Learning from AAA incidents
2.
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 Required
Problem Confirmed - To be managed Internally
SSIs (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

3. Reported LondonAAAincidents (December 2014 to
October 2016)
0
1
2
3
4
5
6
7
8
AAASP1 AAASP2 AAASP3 AAASP4 AAASP5
SI Reported
SSI Reported
Problem Confirmed - To be managed internally
Problem Still Suspected - Further Investigation Required
No Concern - No further action
7 SSI
1 Mgd Internally
2 Still Suspected
2 No Concern
3 SSI
2 Managed Internally
3. Learning from Incidents
3 SSI
1 Managed Internally
1 SI
2 SSI
2 Managed Internally
2 No Concern
2 SSI
3 Managed Internally
2 No Concern
Classification by screening service

4. Open
Closed
Closed – 20
Open – 15
4. Learning form Incidents
Reported LondonAAAincidents (December 2014 to
October 2016)
Incident status

5. 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 27
A 165 38 6 133 283 0 2 7 36 19 3 26 28 124 55 24 167 0 57 19 84 91 16 6 1 0 17
B 71 2 11 13 17 32 215 7 12 1 33 2 9 13 333 0 64 5 0 10 13 41 0 11 3 3 1
C 0 127 19 14 125 46 0 138 0 5 0 161 0 0 338 0 65 7 0 0 37 0 1 19 10 0 0
D 236 137 25 147 408 46 511 145 405 234 0 118 0 0 0 0 0 0 0 0 0 0 16 17 0 0 0
0
100
200
300
400
500
600
D
a
y
s
Days taken to complete each stage of an incident
A = Between Date Incident
Identified and SIAF
Received
B= Between SIAF received
and Section 2 completed
C= Between SIAF received and
Section 3 received
D= Between Incident Identified
and Closure
Timescales for incident management stages
5. Learning from Incidents

6. Themes- incident grouped by similarities
1 5 2 1 1 2 1 2 1 1 4
1
1 5 21
1021
690
62
12 2 Unknown
0 21 13
Number of incidents No of People Affected
Unknown
6. Learning from Incidents

7. 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

8. Lessons Learnt
Theme 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. 9 Learning from Incidents
1 8 3 2 1 1 1
1
1
1 21 5 1 0 Unknown
0 1
326
Number of incidents No of People Affected
Reported NationalAAAincidents
(April to October 2016) Themes

10. 10 Learning from Incidents
Reported NationalAAAincidents
(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