617 Patient Harm Is Underreported Due to an Inadequate Reporting System for Serious Incidents

Abstract

Abstract Aim The Royal Free London Skin Cancer Service (RFL-SCS) is the largest referral centre in London, having received 26,114 two-week-wait referrals since January 2022. Patients are filtered through a complex Skin Cancer Pathway (SCP) involving multiple disciplines (dermatology, plastic surgery, oncology). This root cause analysis of Serious Incidents (SIs) attempts to pinpoint their underlying causes and identify key themes for the re-design of the SCP to ensure patient safety. Method A retrospective analysis of SIs recorded by the RFL-SCS between January 2022 and September 2023 was conducted. Incidents were attributed to various stages in the SCP, which was mapped out in detail. Related information was gathered by interviewing staff at significant points in the pathway and reviewing relevant procedures. A survey of practitioners was conducted to understand if SI reporting through the Datix system was accurate. Results From 26,114 referrals, 1326 needed treatment. 657 of these patients breached the two-week-referral target, with 10 SIs identified. 83% of practitioners surveyed felt that this was an underestimation. Major event types involved no follow-up appointments being booked after: MDT (3); surgery (2); scans (5); patient lost to follow up (1); and poor communication with patients (2). Conclusions System-wide changes must be implemented to prevent SIs from reoccurring. The Datix reporting system was described as convoluted and inadequate, leading to under-reporting of patient harm. More research needs to be conducted in designing an automated tracking system to flag-up and action MDT outcomes for patients with completed excisions, histology, and scans. This will prospectively avoid delays in onward referrals.