This document summarizes themes from quarterly incident reports of a screening program covering October 2015 to December 2017. Key issues identified include screening without informed consent, insufficient samples not being repeated in a timely manner, tracking and communication failures leading to unreported positive screening results, delays when using reference laboratories, and unconfirmed screening results being communicated to patients. The document concludes with a checklist of questions around improving processes to address these issues.

1. Learning from screening
safety incidents
Nadia Permalloo, head of QA development (clinical), PHE

2. Methodology
• nine quarterly incident reports
• covering 1 October 2015 to 31 December 2017
• thematic analysis
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3. Themes
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4. Informed choice
• screening for infections where the woman has declined
Example: woman screened for HIV in error – she had declined screening
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5. Insufficient/indeterminate samples
• screening sample taken and sent to the laboratory. The laboratory reported
onto the electronic system that the sample was insufficient and a further
sample was required for analysis. The sample was not repeated until
submitting KPI data 4 months later
• repeat sample required as initial screening sample was insufficient- this
request was not acted on in a timely manner. Lack of HIV result on tracking
list was not noted
• indeterminate HIV repeat request not undertaken for 11 weeks
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6. Tracking / communication processes
• incomplete antenatal serology spreadsheet for a 2 week period - 4 women
had screen positive hepatitis B results during this time
• delay or failure in reporting positive screening result to screening team
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7. Out of hours laboratory screening service
• women not previously booked for maternity care presenting in labour for the
first time
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8. Using reference labs and transport
• delayed reporting of screening result. Initial screening sample sent to
reference laboratory. Delayed reporting by reference laboratory meant that
the final result was reported 2 months after the sampling
• two samples sent to reference laboratory were delayed. In both cases the
sample was not received and serum had to be resent
• screening samples lost in transit (>100 samples)
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9. Communicating confirmed screening
results
• screening result reported as HIV screen positive before testing was
complete (screening result not confirmed)
• unconfirmed HIV positive result communicated to woman
• presumptive positive result communicated to woman before confirmatory
screening result (which was negative)
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10. Checklist
1. How do we make sure we only test that are requested (informed choice)?
2. How do we makes sure all repeat requests (whatever the reason) are acted
upon in a timely manner?
3. How do we track samples- from request to sample to test to result including
those samples sent to a reference lab
4. How does everyone know how the out of hours lab screening service works?
5. How do we make sure we only communicate confirmed screening results to
maternity services? In cases where we have electronic reporting does
everyone understand what is recorded on the system?
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