|
TVCS meeting
at St Bartholomew's Hosptial on 28 June, 2001.
Dr M J Wilkinson,
James Paget Hospital, Great Yarmouth spoke to us about organising
a major re-screening exercise in full view of the press with very
little notice.
The anatomy
of this incident was set in a small DGH, which received 20-25 000
cervical smears per annum into its cytology department.
When a regional
assessor pointed out a higher rate of cervical cancer in his region,
Dr Wilkinson suggested that the cause might be associated with the
context of the feeder population—very much the ‘hi-di-hi’
of Great Yarmouth.
The next case
of histologically confirmed cervical cancer had been preceded by
a false negative report on a cervical smear - one small group of
cells in the top right hand corner of the slide...same old story.
At the time
they were still doing 10% rescreening as their quality assurance.
However, they were not in a position to answer the possible question
‘Do we have a problem?’ because False Negatives found
were not subject to any rigorous analysis and monitoring.
A few weeks
later when a new checker in the department brought in a missed dyskaryosis
found at QC, he noticed that it originated with the same primary
screener.
When the same screener failed six months later they suspected that
they had a major problem, but let it fester because they didn’t
want to upset her. An in-house team decided that 600 cases would
be rescreened - but no time-scale was set.
It was when
the Health Authority was informed, that an ‘incident’
was declared. Then Uncle Tom Cobley and all joined the team, landing
an organisational nightmare in Dr Wilkinson’s lap. The Chief
Executive made a public announcement declaring a two month timetable
for all the screener’s slides for the past 3 years to be rescreened,
then announced that there would be a press statement six weeks later.
Helplines were set up for patients.
Fortuneately,
when the day for the press interview arrived Dr Wilkinson had the
nearest thing to a reprieve. They let a junior reporter conduct
the interview, and she asked for ‘a worst case scenario’
rather than what actually happened.
Had she asked
what had gone wrong he would have had to say that the results of
the review showed that there was a 33% miss rate of high-grade abnormalities,
and 57% miss rate of low-grade abnormalities. In common with many
labs at that time, the screener was a ‘home’ worker and
it transpired that she was doing her screening in the evenings following
a full-time ‘other’ job.
Nobody at the
press conference asked informed questions, or had any idea about
the test environment. For example, one reporter asked whether working
from home might not be a problem for patients, ‘having their
smears looked at in a non-sterile environment’. Both local
and national press wanted only the ‘dirt’ on the story,
especially the name and address of the screener.
An external
inquiry blamed—as usual—internal conflict and organisational
failures.
While the lab
was rescreening their colleague’s work, the new incoming work
was sent out to another laboratory for primary screening. Ironically,
shortly before his talk to us, the first false negative cervical
cancer from that batch emerged—as it turned out—also a
‘homeworker’.
We all have
our bank of false negatives. When this sort of thing happens to
us, surely we could just call back all women for repeat smear screened
by that screener—instant reassurance for them, less distressing
for us, and would probably cost half as much.
|