Incident: Breast Cancer Screening IT Error: Missed Screenings, Lives at Risk

Published Date: 2018-05-02

Postmortem Analysis
Timeline 1. The software failure incident happened between 2009 and the start of 2018 as mentioned in Article 71214.
System 1. Breast screening invitation programme IT system [Article 71214]
Responsible Organization 1. Public Health England (PHE) [Article 71214] 2. Government IT system for the breast screening invitation programme [Article 71214]
Impacted Organization 1. Women in England who missed crucial breast cancer screenings, potentially leading to 270 deaths [Article 71214]
Software Causes 1. The software cause of the failure incident was a computer algorithm failure that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [Article 71214].
Non-software Causes 1. The failure incident was caused by a major IT error in the breast cancer screening invitation program, leading to missed screenings for 450,000 patients in England [Article 71214]. 2. The error was attributed to a computer algorithm failure that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [Article 71214]. 3. The problem was identified during a review of the progress of a major NHS trial designed to find out whether extra screening would protect older women from breast cancer, indicating a failure in the review process [Article 71214].
Impacts 1. As many as 270 women may have died due to missed breast cancer screenings caused by the software failure incident [Article 71214]. 2. Families faced distressing possibilities that loved ones who recently died from breast cancer may have missed opportunities for early diagnosis [Article 71214]. 3. Women receiving breast cancer treatment, including those with a terminal diagnosis, may receive letters informing them of missed screenings [Article 71214]. 4. Between 135 and 270 women may have had their lives shortened as a result of missed screenings [Article 71214]. 5. 309,000 women who missed screenings were still alive and would be contacted before the end of May [Article 71214]. 6. The error led to a serious failure of the screening programme [Article 71214]. 7. The regular screenings offered to women at risk of developing breast cancer were disrupted [Article 71214]. 8. The software failure incident caused deep disturbance among many families, especially those recently diagnosed with breast cancer or recently bereaved [Article 71214]. 9. The error was identified during an upgrade to the IT system for the breast screening invitation programme [Article 71214]. 10. The software failure incident raised concerns about the effectiveness and oversight of the breast screening programme [Article 71214].
Preventions 1. Regular and thorough testing of the IT system for the breast screening invitation programme could have potentially prevented the software failure incident [Article 71214]. 2. Implementation of additional failsafe systems to ensure errors are caught and fixed promptly could have helped prevent the incident [Article 71214]. 3. Timely detection and resolution of glitches in the IT system could have prevented the software failure incident from affecting a large number of women [Article 71214]. 4. Improved oversight and monitoring of the IT system's performance to catch errors earlier could have been a preventive measure [Article 71214]. 5. Adequate resources and funding for training posts for radiologists to support the screening programme and the NHS as a whole could have contributed to preventing such incidents in the future [Article 71214].
Fixes 1. Implement additional failsafe systems to prevent the recurrence of similar errors in the future [Article 71214]. 2. Conduct a thorough inquiry to establish the root causes of the software failure, determine the extent of the impact, and identify preventive measures for the future [Article 71214]. 3. Ensure timely detection and resolution of IT errors to prevent prolonged failures from going undetected [Article 71214]. 4. Allocate necessary resources, including funding and staffing, to address the increased demand for screenings and treatments resulting from the software failure incident [Article 71214]. 5. Enhance training and resources for radiologists to support the screening programme and overall healthcare system [Article 71214]. 6. Take steps to ensure that there are enough resources in the system to handle any additional demand that may arise due to software failures [Article 71214].
References 1. Health secretary, Jeremy Hunt [Article 71214] 2. Public Health England (PHE) [Article 71214] 3. Dr. Jenny Harries, PHE’s deputy medical director [Article 71214] 4. The AgeX trial [Article 71214] 5. The Royal College of Radiologists [Article 71214] 6. Prof Helen Stokes-Lampard, the chair of the Royal College of GPs [Article 71214] 7. Cancer charities such as Breast Cancer Now and Cancer Research UK [Article 71214]

Software Taxonomy of Faults

Category Option Rationale
Recurring unknown (a) The software failure incident related to the missed breast cancer screenings due to a computer algorithm failure in England is a unique incident that has not been explicitly mentioned to have happened again within the same organization or with its products and services [71214]. (b) The articles do not mention any similar incident happening at other organizations or with their products and services in relation to missed breast cancer screenings due to a computer algorithm failure.
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase was due to a major IT error in the breast cancer screening programme. The error occurred because of a computer algorithm failure that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [71214]. (b) The software failure incident related to the operation phase was due to the failure of the IT system for the breast screening invitation programme. The problem was identified during a review of the progress of a major NHS trial, where it was noticed that women in the trial had not been invited for their final routine screenings before their 70th birthday. This operational failure led to the error affecting an estimated 450,000 women in the routine NHS breast screening programme [71214].
Boundary (Internal/External) within_system (a) within_system: The software failure incident related to the missed breast cancer screenings in England was primarily due to a major IT error within the system. The failure was caused by a computer algorithm failure that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [71214]. The issue was identified during an upgrade to the IT system for the breast screening invitation program, indicating an internal system failure [71214]. (b) outside_system: There is no specific mention in the articles of contributing factors originating from outside the system that led to the software failure incident.
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident occurred due to non-human actions, specifically a computer algorithm failure that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [71214]. (b) The software failure incident also involved human actions as there were concerns raised about why the glitch was not picked up sooner, questions for both Labour and the Conservatives about why the error was not detected earlier, and the need for an inquiry to establish why the error occurred and how it could be prevented in the future [71214].
Dimension (Hardware/Software) software (a) The software failure incident in the article was primarily due to contributing factors that originated in software. The failure was caused by a computer algorithm error that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [71214]. (b) The software failure incident was not attributed to hardware issues but rather to software-related factors, specifically a computer algorithm failure that led to the missed breast cancer screenings for a significant number of women [71214].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident related to the missed breast cancer screenings in England was non-malicious. The failure was attributed to a major IT error, specifically a computer algorithm failure, which resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018 [71214]. The error was described as a serious failure of the screening programme, and the government ordered an independent inquiry into the scandal to investigate why the error occurred and how it could be prevented in the future [71214]. (b) The software failure incident was not reported to be malicious, but rather a result of system errors and failures that were not intentional in causing harm to the system or individuals.
Intent (Poor/Accidental Decisions) poor_decisions (a) poor_decisions: The software failure incident related to the missed breast cancer screenings in England was primarily due to poor decisions. The error was caused by a computer algorithm failure that resulted in an estimated 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018. This failure was described as a serious failure of the screening programme, indicating that poor decisions in the design or implementation of the software algorithm led to the detrimental outcome [71214]. (b) accidental_decisions: The software failure incident related to the missed breast cancer screenings in England was not primarily due to accidental decisions. The failure was attributed to a computer algorithm failure that was not accidental but rather a result of poor decisions in the design or implementation of the screening programme's software [71214].
Capability (Incompetence/Accidental) development_incompetence (a) The software failure incident related to development incompetence is evident in the article. The failure was attributed to a major IT error in the breast cancer screening programme, where an estimated 450,000 patients in England missed crucial screenings due to a computer algorithm failure [71214]. The error went undetected for almost a decade, indicating a serious failure of the screening programme. The Health Secretary, Jeremy Hunt, apologized for the suffering caused and acknowledged that between 135 and 270 women may have had their lives shortened as a result of missed screenings [71214]. (b) The software failure incident related to accidental factors is also apparent in the article. The error was not intentional but rather a result of a fault in the IT system for the breast screening invitation programme. Public Health England (PHE) identified the problem during a review of the progress of a major NHS trial, which led to the discovery that women had not been invited for their final routine screenings as intended [71214]. The error was described as a glitch that was not picked up sooner, raising questions about why it took nearly a decade to identify the issue and whether early warning signs were missed [71214].
Duration temporary The software failure incident related to the missed breast cancer screenings in England was temporary. The failure was due to contributing factors introduced by certain circumstances, specifically an IT error in the computer algorithm that led to the failure to send out invitations for screenings to women aged between 68 and 71 between 2009 and the start of 2018 [71214]. The error was identified during a review of the progress of a major NHS trial, and additional failsafe systems were introduced to ensure the problem does not reoccur [71214].
Behaviour crash, omission, timing, value, other (a) crash: The software failure incident in the articles can be categorized as a crash. The failure led to a significant issue where the system lost state and did not perform its intended functions, resulting in missed crucial breast cancer screenings for 450,000 patients in England [Article 71214]. The error was due to a computer algorithm failure, which caused an estimated 450,000 women aged between 68 and 71 to not be invited to their final breast screening between 2009 and the start of 2018. This failure resulted in as many as 270 women potentially dying due to missed screenings [Article 71214]. (b) omission: The software failure incident can also be categorized as an omission. The system omitted to perform its intended functions at instances where crucial breast cancer screening letters were not sent out automatically to older women registered with their GPs, leading to missed screenings for a large number of women [Article 71214]. (c) timing: The timing of the software failure incident can be considered a factor in this case. The system was performing its intended functions, but it did so too late, as the error occurred between 2009 and the start of 2018, resulting in missed breast cancer screenings for a significant number of women [Article 71214]. (d) value: The software failure incident can also be attributed to a failure in value. The system performed its intended functions incorrectly by not sending out crucial breast cancer screening letters to the targeted group of women, leading to potential harm and even deaths due to missed screenings [Article 71214]. (e) byzantine: The software failure incident does not align with a byzantine behavior where the system behaves erroneously with inconsistent responses and interactions. The failure in this case was more related to a crash, omission, timing, and value issues [Article 71214]. (f) other: The software failure incident can be further described as a failure resulting from administrative incompetence, as highlighted in the articles. The error was a serious failure of the screening program, leading to significant consequences such as missed screenings, potential harm, and even deaths for affected individuals [Article 71214].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death, theoretical_consequence (a) death: People lost their lives due to the software failure - The software failure incident resulted in as many as 270 women potentially dying due to missed breast cancer screenings [71214]. (h) theoretical_consequence: There were potential consequences discussed of the software failure that did not occur - The health secretary mentioned that statistical modeling suggested there were likely some individuals who would have been alive today if the failure had not occurred, indicating a theoretical consequence of potential lives being saved [71214].
Domain health The software failure incident reported in the news article [Article 71214] is related to the **health** industry. The failed system was intended to support the breast cancer screening invitation program within the healthcare sector. The error in the computer algorithm led to approximately 450,000 women aged between 68 and 71 not being invited to their final breast screening between 2009 and the start of 2018. This failure resulted in as many as 270 women potentially losing their lives due to missed screenings, highlighting a serious failure in the screening program [Article 71214].

Sources

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