Guidance

Screening incident glossary

Updated 27 March 2024

A

Adverse event

An event or omission arising during clinical care and causing physical or psychological injury to a patient.

C

Child health records departments (CHRDs)

CHRDs provide a clinical record for all 0 to 19 year olds within a defined geographical area. They are the ‘administrative hub’ supporting the flow of information at an individual and population level. This supports the delivery of universal population health services such as health visiting, screening and immunisations and statutory functions such as safeguarding.

To carry out these functions, CHRDs maintain a child health information system (CHIS).

Clinical commissioning groups (CCGs)

Clinically-led organisations that commission most NHS funded healthcare services on behalf of the population registered with GPs operating within the CCG. These include services that interface with screening. CCGs:

• hold the contracts for maternity services which provide antenatal and newborn screening
• are responsible for commissioning pathways of care and services to treat screen positive patients
• have a quality improvement duty; this extends to primary medical care services delivered by GP practices such as immunisation and screening services.

Clinical governance

A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

Commissioner

An organisation with responsibility for assessing the needs of service users, arranging or buying services to meet those needs from service providers either in public, private or voluntary sectors, and assuring itself as to the quality of those services.

Care Quality Commission (CQC)

The CQC is the independent regulator of all health and social care services in England and must be notified by providers of some care quality issues and safety incidents.

D

Datix

A web-based system for incident reporting widely used by providers of NHS healthcare as part of local incident management arrangements. In NHS trusts this system links to the National Reporting and Learning System (NRLS).

Duty of candour

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 imposed this duty on NHS bodies which supplements professional duties of individual clinical staff.

Health service bodies must act in an open and transparent way in relation to the care and treatment provided to service users. The duty criminalises NHS bodies that fail to notify and apologise to their patients for incidents that have caused them harm.

Incidents are anything unintended or unexpected if it causes or is expected to cause death, severe harm, moderate harm or prolonged psychological harm, including:

• harm caused by the incident rather than the disease or condition
• severe harm – permanent lessening of bodily, sensory, motor, physiological or intellectual functions
• moderate harm – harm that is significant so that it requires a moderate increase in treatment and harm that is significant but not necessarily permanent
• prolonged psychological harm – a minimum of 28 continuous days

H

Health and wellbeing board

Each local authority has a health and wellbeing board, a statutory committee that leads and advises on work to improve health, wellbeing and reduce health inequalities for the population served. Membership includes the director of public health, councillors, commissioners across the NHS, public health and social care; and representatives of patients and the public, including the local Health Watch.

L

Local authority

Provides local government and services for a defined geographical area. Since April 2013, authorities have had responsibility for commissioning or provision of some public health services, health improvement and oversight or scrutiny of NHS services for their resident population.

Director of public health (DPH)

Public health functions are led by the director of public health. There is a director of public health for each upper tier local authority, although a DPH may cover more than one local authority. They are appointed jointly by the local authority and Public Health England (PHE).

Look back

A review of screening records to identify individuals harmed or at risk of harm as a result of a screening safety incident or serious incident. Look backs or case review may also be done as part of fact finding to establish whether there has been a screening incident. Look backs may result in a patient notification exercise or recall.

Local offices of NHS England regions

NHS screening and immunisation services are commissioned by staff working in local offices. They ensure that service providers deliver against the national service specifications and meet agreed quality standards. They ensure adequate responses are made to QA recommendations and use commissioning levers to implement change where necessary.

M

Medical device

Medical devices and equipment are items used for the diagnosis and/or treatment of disease, for monitoring patients, and as assistive technology. This does not include general purpose laboratory equipment. Any incidents involving medical devices should be reported using the online form.

N

National Patient Safety Agency (NPSA)

The NPSA was set up in July 2001 following recommendations from the chief medical officer in his report on patient safety An organisation with a memory. Its role was to improve the safety of patients by promoting a culture of reporting and learning from patient safety incidents. Its guidance and resources to manage and investigate serious incidents are still applicable. NPSA functions were absorbed into NHS England in April 2013. Patient safety functions of NHS England were absorbed into NHS Improvement (NHS I) in 2017 to 2018.

National reporting and learning systems (NRLS)

A confidential and anonymous electronic reporting system developed by the NPSA for the collection and analysis of patient safety incident information. It receives incident reports from NHS organisations, staff and contractor professions and, in time, patients and carers.

NHS England (NHSE)

NHSE provides strategic direction and oversight of the NHS. Its vision is that everyone has greater control of their health and their wellbeing, supported to live longer healthier lives by high quality health and care services that are compassionate, inclusive and constantly-improving.

NHS I will also seek to support implementation of this best practice through more direct engagement with Trusts and Foundation Trusts through its regional teams.https://signon.publishing.service.gov.uk/

NHS Improvement (NHS I)

NHS I is responsible for overseeing NHS foundation trusts, NHS trusts and independent providers. NHS I offer the support NHS trusts and NHS foundation trusts need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable.

NHS I has taken over the responsibility from NHS England for providing national guidance for managing Serious Incidents. This guidance will provide the framework upon which CQC and commissioners (including CCGs and NHS England) will assess the quality of investigations undertaken across the NHS.

Near miss

Situations that could have resulted in an accident, injury or illness for a patient but were avoided by chance or by intervention.

Never event

A list of serious, largely preventable patient safety incidents that would not have occurred if the available preventative measures have been implemented. There are no screening incidents in this list.

NHS standard contract

The NHS standard contract is mandated by NHS England for use by commissioners for all contracts for healthcare services other than primary care.

NHS screening programmes

The NHS screening programmes are supported and advised by PHE. PHE sets and reviews standards, develops information materials for the public and education and training strategies for screening staff. It also provides operational support to local screening services.

P

Public health commissioning central team

This team is to be contacted by email if a screening incident needs need escalating to NHS England regio or national level or if the suspension of screening is recommended (england.phs7apmo@nhs.net). The team has a protocol for regional and national incidents. It is led by the NHS England’s director of commissioning system change and public health commissioning within the medical directorate.

Public health commissioning in NHS England

Each sub-region’s public health commissioning team comprise NHS England’s own staff (led by the head of public health or public health commissioning lead) and also ‘embedded’ PHE staff, (led by screening and immunisation leads). In some sub-regions the screening and immunisation lead carries out both roles.

Patient safety

The process by which a provider of health care improves the safety of patient care. This should involve risk assessment, the identification and management of patient-related risks, the reporting and analysis of incidents, and the capacity to learn from and follow-up on incidents and implement solutions to minimise the risk of them recurring.

Patient safety incidents, screening safety concerns, safety incidents and serious incidents

Patient safety incidents are incidents that could have or did harm a patient receiving NHS funded care.

A safety concern in a screening programme is where an event or set of circumstances is reported that may meet the definition of a screening safety incident or serious incident.

Screening safety incidents are incidents that could have or did harm to one or more persons participating in the screening programme, or to staff working in the screening programme; or because one or more people eligible for screening were not offered screening.

Serious incidents in screening programmes are of greater severity than screening safety incidents in that individuals, the public or staff would suffer avoidable severe harm or death if the root cause is unresolved.

Patient notification exercise

Members of the public identified as at potential risk of harm or harmed due to a screening incident are contacted by the screening service and informed of the quality problem. They can be offered repeat screening (recall to screening). Patient notification commonly occurs following a look back.

Public Health England (PHE)

An executive agency of the Department of Health that began operating on 1 April 2013. It is a national organisation with a remit to protect and improve the nation’s health and wellbeing, and reduce health inequalities. It provides expert public health advice, support and services, tailored to local needs. It is responsible for NHS screening programmes and SQAS. These functions are managed by the screening division of PHE’s health and wellbeing directorate.

PHE regions

There are 4 PHE regions with the same boundaries as NHS England regions. Each is headed by a Regional Director of Public Health. They provide evidence based public health and population healthcare advice and focus on supporting localities and linking with NHS England.

PHE centres and centre directors

There are 8 PHE centres that are the front door for most of PHE’s local services across health improvement, public health and health protection. They support the challenge and scrutiny role of Local Authority directors of public health (DsPH) through the dissemination of evidence and intelligence.

Each PHE Centre is led by a PHE centre director. They provide professional support to the PHE staff embedded in the NHS England sub-regional teams. PHE Centres lead the response to outbreaks of vaccine preventable disease and provide expert advice to screening and immunisation teams in cases of immunisation incidents.

PHE Screening quality assurance service (SQAS)

PHE Screening’s quality assurance service (SQAS) has a quality assurance remit for all NHS screening programmes in England. It was formed in April 2015 from cancer screening QA reference centres and the regional screening QA teams for antenatal and new born screening, diabetic eye screening and abdominal aortic aneurysm screening. It is part of the screening division.

Its purpose is to ensure local screening programmes operate within national standards and guidance - from identification of the cohort eligible for screening to referral out of screening into treatment or intervention services.

SQAS has an advisory role in screening incident management and leads on monitoring and sharing lessons identified from incidents and developing incident management guidance.

These functions are carried out through a programme of QA activities by a national team and 4 regional teams, one for each PHE and NHS England region.

Find contact details for the SQAS regions.

Q

Quality surveillance groups (QSGs)

These NHS England-led virtual teams operate at a regional or sub-regional level bringing together organisations across the health economy. Each QSG works to safeguard the quality of care that people receive by collectively considering and triangulating information gathered through performance monitoring, commissioning, and regulatory activities and intelligence sharing intelligence and information.

R

Regions

NHSE is organised into 4 regions – North, Midlands and East, South and London. NHS England regions are the organisational level used to escalate concerns around quality in local screening programmes. Each region has a number of local offices.

Risk

The likelihood of something happening that will harm individuals, the public and/or organisations. It is assessed in terms of likelihood and severity of the consequences.

Risk management

Identifying, assessing, analysing, understanding and acting on risk issues in order to reach an optimal balance of risk, benefit and cost.

Root cause analysis (RCA)

A systematic process whereby the factors that contributed to an incident are identified.

As an investigation technique for patient safety incidents, it looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which an incident happened.

S

Screening and immunisation lead (SIL)

Consultant in public health who leads a Screening and Immunisation team. Employed by PHE but line managed and works within NHS England at sub-regional level. Professionally accountable to a PHE centre director.

Screening and immunisation team (SIT)

Embedded within local offices of the 4 NHS England regions, these teams provide local system leadership and commissioning of screening and immunisation services. Each team comprises:

• screening and immunisation lead(s) (public health consultant)
• screening and immunisation managers
• screening and immunisation coordinators

Screening programme board

Provides governance and oversight of a local screening programme. Typically chaired by a screening and immunisation lead with representation from all providers and staff groups that contribute to the screening programme and SQAS (regional).

Strategic executive information systems (STEIS)

The national information system which enables the electronic logging, tracking and reporting of serious incidents.

Systems failure

A fault, breakdown or dysfunction within operational methods, processes or infrastructure

U

UK National Screening Committee (UK NSC)

UK NSC advises ministers and the NHS in the 4 UK countries about all aspects of screening. The UK NSC secretariat is hosted by PHE.