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Service development I
PMO-010 Improving the adverse event reporting process for bowel screening Wales
  1. C Lewis
  1. Bowel Screening Wales, Public Health Wales, Llantrisant, UK

Abstract

Introduction Risk management is an essential part of the clinical governance framework and central to this is adverse event reporting. The aim of this study is to increase the number of adverse events reported to Bowel Screening Wales (BSW).

Methods The primary research method included a literature review. The focus for the study was adverse event reporting and recording methods. Referral patterns were recorded prior and post intervention and the data compared. The literature review informed the various processes adopted in an attempt to increase referrals for adverse events from the Local Assessment Centres (LACs). The interventions took place in all LACs throughout February 2011. They included defining and providing examples of adverse events, educating the Specialist Screening Practitioners (SSPs) and providing a more flexible approach for reporting. A file using Microsoft Office Excel was developed to categorise referrals by subject and consequence. Referrals from the beginning of the programme were collated, categorised, given a consequence score and recorded in this file. This allowed for a baseline to compare against future referrals.

Results The number of adverse events reported from the launch of BSW on 27 October 2008 until 30 January 2011 was 54. This compared to 100 adverse events reported during the time period 1 February 2011 to 27 November 2011. Referrals have increased fivefold since the intervention took place. Standardising the categories and consequences allowed for monitoring and comparison on the types of events reported to BSW per LAC. This helped to focus appropriate intervention including further education for reporting where it was needed. The type and severity of adverse events reported post intervention increased for the more minor and more serious adverse events. The less serious categories 1 and 2 saw almost a sevenfold increase in the rate of reporting while the more serious categories 3, 4 and 5 experienced an increase of 1.5. There was concern that serious incidents went under-reported prior to the intervention. However, this evidence is re-assuring in that the rate of reporting is far higher for the more minor events post intervention than for the more serious events. The information for the more serious events was cross-checked retrospectively with the SSPs around Wales who confirmed these findings.

Conclusion The primary aim of the study was achieved and the annual rate of adverse events reporting to BSW has increased fivefold. Ongoing education is required to ensure adverse event reporting does not get forgotten and certainly until the process has become embedded in practice. The process and framework has enabled BSW to collate information providing a consistent approach for regular review and monitoring of adverse events by the BSW programme.

Competing interests None declared.

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