UK Panel Finds "Unacceptable" Errors Made by Breast Screening Service

"Unacceptable and avoidable" errors were made by a London breast screening service, according to the U.K. Commission for Health Improvement.

The problems included communicating results to patients and recalling the correct patients for re-examination.

The West of London Breast Screening Service, part of Hammersmith Hospitals NHS Trust, caused 123 women to miss being recalled for urgent further assessment after their screening.

Eleven women experienced delays of up to 21 months before their diagnosis. Ten of the women are currently undergoing treatment for breast cancer. One woman died of breast cancer after facing a delay of 15 months before receiving a diagnosis.

A confusing notation that differentiated between routine recall and urgent recall was cited as the primary reason for the mix-up. Other issues found during the commission's investigation included failure to implement national guidelines, lack of clear accountability, staff shortages, and poor working relationships. The service also had inadequate safeguards in place to ensure that screened patients received the correct results.

The facility had failed to change its policies after previous errors had been found in 1994 and ignored recommendations made by quality assurance teams. The quality assurance teams, in turn, failed to follow up to make sure their recommendations had been adapted.

These findings are a "wake-up call" for all breast screening services, according to Dr. Linda Patterson, medical director of the commission. "The focus must be kept on patient safety."

The commission is recommending a greater degree of standardization in breast screening programs, including notation, and a review of the procedures and responsibilities of its external quality assurance teams, with stronger emphasis on follow up.

Other Sources: British Medical Journal