This document provides guidance on incident management and root cause analysis for NHS screening programs. It describes what constitutes a screening safety incident and outlines requirements for managing safety concerns, incidents, and serious incidents. The Safety Incident Assessment Form is used for fact-finding and recommending actions. It also discusses accountability, roles, and responsibilities and recommends using a RASCI framework. Root cause analysis is described as an evidence-based process to identify the underlying causes of problems in order to develop targeted actions to prevent recurrence.

1. Incident Management
&
Root Cause Analysis
 NHS England Adult Screening  Thursday 10 November 2016
Deepak Rikhi, Commissioning Manager, Adult Screening,
NHS England (London)

2. Managing Safety Incidents in NHS
Screening Programmes
 Providers, Commissioners and QA should all have the read the
“Managing Safety Incidents in NHS Screening Programmes”. This
can be found on the GOV.UK website:
https://www.gov.uk/government/publications/managing-safety-
incidents-in-nhs-screening-programmes
 The documents:
 Describes what is a screening safety incident
 Provides guidance that sets out the requirements
for managing safety concerns, safety incidents and
serious incidents in NHS screening programmes

3. Safety Incident Assessment Form (SIAF)
 The SIAF assessment form is used for:
Fact finding
Recommendation for action

4. Accountability, roles and responsibilities for
managing screening safety incidents and serious
incidents
All parties should agree on accountability, responsibilities
and governance. A RASCI framework should be used to aid
this.

5. RASCI Framework
Responsible
• who is responsible for carrying out the entrusted task?
Accountable
• who is responsible for the whole task and who is responsible for what has been done?
Support
• who provides support during the implementation of the activity / process / service?
Consult
• who can provide valuable advice or consultation for the task?
Inform
• who should be informed about the task progress or the decisions in the task?

6. Responsible
• Where along the pathway did the incident occur?
• If the incident occurred in the screening part of the pathway only, than
the Screening Programme is responsible for leading on the incident.
• If the incident occurred in the treatment part of the pathway only,
than the Trust hosting the vascular service is responsible for leading on
the incident.
• If the incident involves multiple providers, than the Commissioners
will lead on the incident
• QA responsible for providing advice on methodology for investigation.

7. Responsible
• What does being Responsible mean?
• Investigate the incident, i.e. completing
the RCA
• Arranging and chairing meetings, such as
incident panels, ensuring all stakeholders
are invited. This would also include the
minuting of such meetings
• Keep all stakeholders informed of
progress

8. Accountable
• This is not always obvious and can be confusing.
• The Lead/Director of the service provider leading
the incident is accountable for the incident
• The Accountable Commissioner (NHS England
that commission the service) is accountable for
having oversight and closing off of incidents.

9. Support
• These will be individuals or organisations
that help those leading an incident in
completing the task, e.g. if an incident has
occurred with a screening of an image, the
CST will support the Programme Manager in
the investigation, or the Trust Management
providing resource.

10. Consult
• Who can help?
• Those leading on the incident should look towards QA
and Commissioners as a minimum of those that can
consult on the incident process.
• It should also be any person or organisation that will
help in the investigation, outcomes and lessons
learned, e.g. if a patient dies during the treatment
pathway, the vascular consultant would be consulted to
provide expertise that would inform the investigation

11. Inform
• Relevant stakeholders need to
notified on the progress,
outcomes and lessons learned,
e.g. the Directors of Public
Health, CCGs, etc.

12. Root Cause Analysis
 Root Cause Analysis is an evidenced based, structured
investigation process which utilises tools and techniques
to identify the true causes of an incident or problem, by
understanding what, why and how a system failed.
 Analysis of these system failures and true causes enables
targeted and, where possible, failsafe actions
 to be developed and implemented which demonstrate
significantly reduced likelihood of recurrence
Taylor-Adams (2011)

13. Basic elements of RCA investigation
WHAT
happened
HOW it
happened
WHY it
happened
Unsafe Acts Human
Behaviour
Contributory
Factors
Solution Development & Review of effectiveness
‘WHO did it’
is not the objective

14. Why RCA?
 To prevent an incident happening again
 In depth analysis of a small number of incidents
will bring greater dividends than a cursory
examination of a large number.
Vincent and Adams - 1999

15. Why RCA?
 To err is Human
 To cover up is unforgivable
 To fail to learn is inexcusable
Sir Liam Donaldson
 Hope is not a strategy...
Aiden Halligan

16. Key Points – What is RCA?
 RCA Investigations provide a systematic means of
reviewing and learning from incidents
 The scale of the patient safety problem is still not
clear...
 ...But it is significant, and to fail to learn in inexcusable

17. Manage Affected Subjects
 Ensure affected subjects do not come to harm
 Ensure appropriate communication to affected
subjects