The Quality improvement review of a screening event in the Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP) details the findings into an incident which led to 2000 babies being recalled for newborn hearing screening.
Since 2010 all 20 district health boards (DHBs) have offered hearing screening to newborns as part of the UNHSEIP. The programme aims to identify babies with moderate to severe permanent hearing loss early, so they and their families can access timely intervention to support the development of speech and language.
An investigation by the National Screening Unit (NSU) found that some screeners at six DHBs had not carried out screening according to the Universal Newborn Hearing Screening and Early Intervention Programme protocol. The investigation identified that these screeners were not correctly testing the babies’ ears and therefore potentially missed detection of hearing loss.
Purpose
At the request of the Director, National Services Purchasing, the National Screening Unit, with the input of an Incident Review Group, undertook a review of an event in the Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP).
Between July and November 2012 an issue in the screening pathway was identified whereby approximately 2,000 babies between 2009- 2012 were not screened correctly for permanent congenital hearing loss. The scope of the review was as follows.
- To describe and document the incident and outcomes.
- To as far as possible understand the causal factors of the non- protocol screening.
- To identify contributory factors that may increase the potential for non-protocol screening, including organisational and national level factors.
- To identify recommendations for changes in DHB service provision that will enhance screener quality assurance.
- To identify recommendations for changes to the national provision of the UNHSEIP that will strengthen the programme and reduce the likelihood of similar events.
- To make any other recommendations based on the information obtained during the course of the review.
Key Results
The investigation has made 21 recommendations aimed at strengthening both DHB service provision and the leadership and monitoring of the programme by the NSU. These include:
- greater access to training
- professional development and support for screeners
- better monitoring of the equipment screeners use and the information they collect
- clearer guidance on following protocol establishing a clinical governance framework for the programme in DHBs
- setting up a national database for quality monitoring.