1) An audit of AAA screening program operational meetings found variable compliance with standards, with only half meeting monthly as required. Key learning included developing terms of reference and improving meeting attendance and record-keeping. 2) An analysis of AAA screening incidents in London from 2014-2016 identified 17 screening safety incidents and 1 serious incident reported, with varying timescales for investigation. Themes included issues with ultrasound machines, delayed letter printing, and unregistered patients. 3) Lessons from national AAA screening incidents from April-October 2016 involved 21 reported incidents affecting 466 people. Themes included hospital referral delays and strengthened medical history checks. Improved tracking processes and administrative support were recommended.

1. Public Health England leads the NHS Screening Programmes
CST and Screening Technician
Workshop – 10 November 2016
-What we can learn from audits and
reported AAA screening incidents
Paola Beresh, QA Advisor, SQAS (London)

2. Audit
 Last study day held in November 2015, we had a presentation by Dr
Louise Wilkinson, Director of Screening/Consultant Radiologist for the
South West London Breast Screening Service on the importance of audit
within screening programmes
 Audit can be used to assess, evaluate and improve standards
So what learning have we done so far?
2 Learning from Audit

3. For example
Screening Centre Meetings Audit
3 Learning from Audit

4. Standard/Service Specification
Audit should measure current practice against a defined (desired) standard:
Standard/Service Specification:
NHS England’s NHS public health functions agreement 2016-17 service
specification No.23 states that:
• an internal multi-disciplinary operational group is established
• this group meets monthly as a minimum.
• this group will ensure robust operational processes are in place between
individuals delivering the services
4 Learning from Audit

5. Audit Methodology
5 Learning from Audit
Each of the five AAA screening programmes were asked to complete a proforma
confirming:-
 terms of reference
 how often meetings are held
 who is invited
 are minutes taken
 dates of meetings held in the last 6 months.

6. Results
Terms of Reference
Yes
No
No
- 4
Yes
- 1
6 Learning from Audit
 Only 1 out of 4 screening
programmes had a terms of
reference

7. Results
0 1 2
Weekly
Monthly
Twice in 6 months
Once in 6 months
Meetings Held in last 6 months
Screening Programme
7 Learning from Audit
 Variable
 2 out of 5 screening programme are achieving the
standard of meeting at least once a month as
outlined in the service specification

8. Results
Invited
(Attendance% in
last 6 months):-
Clinical
Lead
Programme
Manager
Screening
Technician
CST Vascular
Nurse
Specialist
Admin
Screening Centre 1 No
(0%)
Yes
(100%)
Yes
(100%)
No
(0%)
Yes
66%
Yes
(100%)
Screening Centre 2 Yes
(0%)
Yes
(100%)
Yes
(100%)
Yes
(33%)
Yes
(0%)
Yes
(100%)
Screening Centre 3 Yes
(0%)
Yes
(100%)
Yes
(100%)
Yes
(0%)
Yes
(0%)
Yes
(0%)
Screening Centre 4 Yes
(0%)
Yes
(100%)
Yes
(100%)
Yes
(100%)
Yes
(100%)
Yes
(100%)
Screening Centre 5 Yes
(Unknown
– not
minuted)
Yes
(Unknown –
not minuted)
No Yes
(Unknown
– not
minuted)
No No
8 Learning from Audit
 3 out of 5 screening programme invited all screening
programme personnel
 No attendance by Clinical Lead
 Only 1 in 5 had a CST present
 Variable attendance by VNS and Admin

9. Results
Yes - Typed
3
Yes –
Not Typed
1
No
1
Minuted
9 Learning from Audit
 4 of 5 of the screening programmes took minutes
from their meetings
 However 1 of those took minutes but were not
typed

10. Recommendations
 To hold meetings once a month in accordance with service specification
 To produce a terms of reference outlining quorum and attendance to
meetings by key representatives of the screening programme
 To minute and audit meetings on a regular basis
10 Learning from Audit

11. Learnings from AAA Incidents
11 Learning from Audit

12. Definitions
A screening safety incident (SSI) is:
• any unintended or unexpected incident(s), acts of commission or acts of
omission that occur in the delivery of an NHS screening programme that
could have or did lead to harm to one or more persons participating in the
screening programme, or to staff working in the screening programme
• harm or a risk of harm because one or more persons eligible for screening
are not offered screening.
A serious incident (SI) is:
• an incident which has consequences that are so significant to individuals,
families and carers, populations, staff or organisations, or represent such
significant potential learning for the NHS, that a heightened level of
response is warranted.
(Managing Safety Incidents in NHS Screening Programmes – Oct 2015)
12 Learning from AAA Incidents

13. Reported LondonAAAincidents
(December 2014 to October 2016)
13. Learning from AAA Incidents
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

14. 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
14. Learning from AAA 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

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

16. 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
16. Learning from AAA Incidents

17. 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
17. Learning from AAA Incidents

18. Lessons Learnt
18 Learnings from AAA 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

19. 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
19 Learnings from AAA Incidents

20. 20 Learning from AAA 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 National AAAincidents
(April to October 2016)
Themes

21. 21 Learning from AAA Incidents
Reported National AAAincidents
(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