A number of weeks ago the Clinical Audit Support Centre were contacted by an expert local clinical audit and QI professional to tell us about a recent experience that his Trust had with a national audit. To cut a long story short and not to misquote the person who contacted us, they wrote in their email ‘the NCA incorrectly recorded another Trust’s data against ours, which made us an outlier. We had to review every single piece of information they used and check its accuracy before the NCA supplier would admit they were in the wrong. The upshot of this is we now have a clinician stamping his feet because he wants a database setting up to collect mirrored data to allow us to make sure the data being collected is accurate. There was no apology [from the NCA supplier] and seemingly no accountability’.
The person who contacted us then went on to explain that this exact same error had recently occurred with a different national clinical audit!
It is honestly difficult to know how to respond, isn’t it? While we all understand that mistakes happen and that none of us are perfect or bullet-proof, these two examples that relate to just one Trust, raise huge concerns. As we all know when patient test results are mixed up, the story will extend to at least two patients or in this case two Trusts that have been given incorrect feedback! And added to that, with the CQC currently placing so much emphasis on data and results from national clinical audit, a mix-up of this nature could have a huge impact on the outcome of an CQC inspection. The irony here is that as the Trust in question now move towards adopting a new database to record all their NCA results they will now be in a unique position to check that NCA supplier feedback is accurate while also ensuring there is no delay in gaining results from national audits they participate in! Of course, the downside of this is that the workload involved will be absolutely massive and local audit and QI projects will inevitably suffer as a result.
Away from clinical audit we do lots of training in root cause analysis/patient safety and many of you will be aware of the NHS ‘never events’ initiative. If not, click here. As the label suggests ‘never events’ are viewed as ‘serious incidents that are wholly preventable’. For us, these two incidents are never events and they got us thinking about whether it would be possible and sensible to draw up a short-list of never events that all NCA suppliers must report and review using root cause analysis. We floated the idea on Twitter recently and it seemed to go down very well. Indeed, we have already had a number of suggestions from the excellent James Andrew (see @ThatMrAndrew) in terms of what could be included, for example: data entry website without a padlock (HTTPS), audit commencing without a stated date of report publication and unmanned NCA support office in the run up to and through data entry deadline. We could set-up a simple NRLS-style incident database for all NCA suppliers and users to register, share and learn from problems.
For us the most common complaint we hear of in relation to NCAs is delays in reporting results. For us a never event would be any national clinical audit producing their report or feeding back data to participants more than 12 months after data was collected and uploaded. And another never event would be any NCA supplier website, not making their audit data collection forms and tools available online. Let’s remember all these projects are funded by the taxpayer so there should be clear accountability and transparency allowing patients and the public to see what is being collected and how data is used to improve care.
On a final note, we’d love to hear what you think… and your experiences of NCAs. We’d like to believe that the cases we have reported at the start of this article are very rare. Fingers crossed no one else will come forward with remotely similar experiences. But please do also take a moment to suggest what you would regard as ‘never events’ for NCAs. Drawing up a list of 10-12 as we do for clinical care, would surely make a lot of sense. As with patient care, we could use NCA-related never events to stimulate discussions, implement improvements and share important learning lessons.