“Unacceptable” errors found in breast screening serviceBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7343.933 (Published 20 April 2002) Cite this as: BMJ 2002;324:933
The UK government's health services watchdog, the Commission for Health Improvement, has found “unacceptable and avoidable” errors in a London breast screening service.
There was no evidence of inaccurate diagnosis for the service, which achieves above average targets for cancer detection.
The problems arose in communicating the results to patients and recalling the correct patients.
The mistakes at the West of London Breast Screening Service, which is part of Hammersmith Hospitals NHS Trust, led to 123 women not being urgently recalled for further assessment after screening.
Eleven women endured delays of up to 21 months before diagnosis. Ten of the women are currently being treated for breast cancer. But one, whose diagnosis was delayed for 15 months, has died of the disease.
Over 174000 screening episodes dating back to 1993 were reviewed by the trust, prompted by the discovery in October 2000 that a woman screened by the service had been sent the wrong results.
The commission report highlights confusing notation—using “RR” and “recall recall” to differentiate between routine recall and urgent recall appointments—as “creating far too great a potential for error.”
Failure to implement national guidelines, lack of clear accountability, staff shortages, and poor working relationships were also key factors, it said. And the service lacked rigorous safeguards and protocols to ensure that screened women received the correct results.
The west London service failed to change policy after previous errors or learn from similar mistakes made in Birmingham in 1994. And it ignored crucial recommendations made by external quality assurance teams, which in turn failed to ensure that these had been carried out.
Dr Linda Patterson, the commission's medical director and lead researcher for this investigation, described the findings as “a wake-up call” for all breast screening services. “The focus must be kept on patient safety,” she said.
The commission wants regular checks by NHS trusts to ensure that national guidance is being followed, and specification in service level agreements that compliance is compulsory.
The commission recommends a greater degree of standardisation in the working guidance of the NHS breast screening programme, including notation, and a review of the procedures and responsibilities of its external quality assurance teams, with stronger emphasis on follow up.