https://phescreening.blog.gov.uk/2017/11/16/its-so-helpful-to-share-learning-from-safety-incidents-in-screening/

It’s so helpful to share learning from safety incidents in screening

I’m the antenatal and newborn screening coordinator at Wirral University Teaching Hospital NHS Foundation Trust.

I always look forward to the regular regional networking events hosted by PHE’s Screening Quality Assurance Service (SQAS) in the north of England. I’m usually just a delegate but at the most recent event the SQAS team asked me to share learning from a screening safety incident in the fetal anomaly screening programme.

Preparing my talk

The safety incident arose after a routine audit of ultrasound practice. This highlighted the need to put additional support and training in place for one of our practitioners.

I enlisted the help of a sonography colleague and we set about reflecting on how we had managed the problem. This helped capture learning from another person’s perspective. I would probably have been missed some important points without their input.

In preparing the presentation, we thought about:

  • the internal processes we had used to review what had happened
  • how we had escalated the problem
  • what support we were offered at the time
Thought bubble
Sharing experiences from screening safety incidents with your peers means you can learn from each other

Learning points

At the networking event, I talked about how we had dealt with the situation and explained that by reporting the incident we had helped ensure the safety of screening in future. We learned that it helps to:

  • escalate problems early
  • get all professional disciplines involved, for example SQAS, midwifery, sonography, screening and immunisation teams
  • get the right expertise to help you think through the potential harm and risks
  • use national guidance to help you through step by step, for example applying managing screening safety incidents and duty of candour guidance
  • have good governance arrangements for any audits that are done or scheduled
  • use internal processes to highlight audit non-compliance
  • promote electronic reporting of incidents
  • support sonographers’ continual professional development

Reflections

My presentation went well and generated lots of discussion among peers. It highlighted the extent of the work required in these situations, from identifying a problem to closing an investigation. Most importantly, it proved how helpful it is to share experiences with your peers so we can all learn from each other.

I’d be lying if I said I didn’t have concerns about doing the presentation. I was worried we would be criticised and it would be received negatively. Thankfully this was not the case; in fact it was quite the opposite as the following comments from a midwife and a sonographer prove.

We will have a review of our supervision processes for all our new staff members.

A really interesting and thought-provoking account of the incident which we have all learned from.

Now I have had the opportunity to present at the forum, I’ll be more confident about sharing learning experiences in the future. After all, as the late actor Robin Williams said, it is “words and ideas that change the world”.

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