Diabetic eye screening: learning from incidents
Updated 2 October 2023
Applies to England
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We provide the following scenarios to demonstrate what can go wrong when there are no checks in place or when checks are not robust or timely.
1. Mislaid notification
A GP had notified the service of a person who had been newly diagnosed with diabetes. However, the service mislaid this notification and the person was not invited for screening until the list of patients at that GP was validated several months later.
2. Incorrect codes
Incorrect codes were being used in a GP practice to record someone as having diabetes. The details of the individual was therefore not included in the monthly data extract to the screening service
3. Failure to re-invite
A person had requested to be opted out of screening for 3 years. However, the service failed to re-invite this person after this timeframe due to not completing timely internal failsafe checks.
4. Incorrect ineligibility
A person had been recorded as ineligible for screening due to no perception of light (NPL) in both eyes without making appropriate checks. When this ineligible state was audited, it was found that the person was eligible and should have been invited.
5. Images saved to wrong record
Images taken of one individual were saved with another person’s details. This led to incorrect results being sent to both individuals.
6. Lack of image synchronisation
Because a laptop containing images taken in a screening clinic was not synchronised to the server, images and patient records were not transferred for 3 months. This resulted in patients having an incorrect do not attend (DNA) status – when in fact they had attended an appointment.
7. Referral letters not generated
Sixteen people had their referral to hospital eye services (HES) delayed due to a software fault, which meant referral letters for each of them were not generated when they should have been. All these people experienced a delay in being seen by an ophthalmologist and getting access to treatment.