By Fiona Murphy, Chief Executive, National Screening Service
Invariably it starts on a Friday. A call comes in: "I think we have an incident".
Incidents, as with any healthcare system, are common in screening. We screen over half a million people a year, at thousands of locations, through multiple IT systems, accessed by hundreds of people. We have strict procedures and systems in place to protect from error, but some are inevitable.
Screening itself also uses some very subjective tests and it is accepted worldwide that screening has a wide error range. That would not be acceptable in a health service for sick people but it is considered worth it for the benefit screening brings for a huge population; one of the highest volume services in the country.
You can read more about screening benefits and harms of cervical screening here.
Quality Control and Quality Assurance are the gold standard in screening to protect from error. But incidents and errors still happen. And we also need systems in place to deal with them. We call this our Incident Management Framework.
Sometimes we are alerted to a problem when a participant calls us to tell us something unusual has happened. Sometimes it will be through our regular checks of our processes. Often though it will be a member of staff identifying that something is not working properly.
Initially the responsible team will do a rapid risk assessment:
- Are any patients at immediate risk?
- Do we need to alert others?
If we have a high level of concern, we set up a Serious Incident Management Team (SIMT). This will be run by a member of the management team and involve people from the service affected, quality and risk team, public health expertise, communications and IT if needed. The team works through the problem until it is resolved. Part of the work will be the plan for communications with any affected people. We operate a people-first communications policy: That is, the people affected are informed first. We follow the HSE Open Disclosure policy to ensure all patients are advised what has happened, give an apology and - importantly – we tell them how we plan to reduce the incident happening again. At the same time, we look at communication with the others impacted by the incident (service providers, healthcare professionals). The HSE chief clinical officer is also briefed on the incident.
A number of incidents in the last few years have demonstrated this approach, for example, when we had a capacity incident at one of our laboratories and samples expired or when some patients were not seen for treatment in the time required.
Our approach is always threefold:
- resolve the immediate problem
- inform and apologise to people affected
- put in a longer-term plan to reduce the chance of it happening again
We also add the risk of this happening to our risk register, if appropriate. Risk registers are our list of risks that have the potential to adversely impact a participant or the programme overall. We keep a record of the controls we have in place and the actions needed to reduce the risk. It is a dynamic list we update regularly.
What about screening errors?
There are also errors regarding screening samples themselves. This is rare but also inevitable in screening as it is agreed internationally that screening tests are imperfect, but appropriate for a population-based screening programme.
We use international standards and quality control measures to reduce the chances of mistakes. For example, every mammogram and every cervical screening sample is reviewed twice by two highly-trained professionals to reduce the risk of errors. If we discover an error, we will always let patients know. Examples could include identifying at the multidisciplinary team meeting of staff when screening cases are discussed, that the cytology result needs to be re-graded. Biopsy results taken at colposcopy are more accurate and this can upgrade or downgrade the original cytology result. If that happens the doctor in colposcopy will inform the women and discuss the next steps in treatment with her. These types of interactions with patients happen all the time in screening services. They are Open Disclosure in real time
Patient-requested reviews
Patient-requested reviews in cervical screening are to support women (or their families) if a diagnosis of an invasive cervical cancer is made after participation in a screening programme. They are not primarily about errors. We know from international evidence that the vast majority of reviews will find that screening was satisfactory and within the 95% proficiency expected of screeners. We anticipate less than 5% being due to error; this is in line with international expectations of screening.
Patient reviews are to help patients through a discussion of the screening journey they had, before they developed cancer. Any errors identified will be subject to Open Disclosure as part of that discussion; however, the review takes a more holistic approach for patients. They are mindful of the support needed and are delivered with the patient in the driving seat. You can find out more about patient requested reviews here.
Sometimes in healthcare it’s not obvious that an error has occurred or whether a patient has come to harm. What is important to us is that once we do know, we are honest and open about it, informing patients and other stakeholders if necessary, and at all times using our systems to keep all error to a minimum.