Advanced Digestive Endoscopy: Practice and Safety

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Our findings reinforce the need to adopt a systems approach when dissecting the causes and consequences of error. Also it should be noted that policies and protocols to prevent many of the observed PSIs were already in place but not necessarily adhered to. For example unit protocols for administering and monitoring sedation safely follow the British Society of Gastroenterology BSG guidance 28 , but there was variation in sedation practices between endoscopists.

Evidence-based protocols are a necessary first step but are likely to need reinforcement via teamwork and educational interventions. The majority of PSIs recorded in this study were minor errors and often there were no immediate consequences. However, given that major errors frequently arise from a series of minor errors an association we also observed here minor problems are important to address for error prevention. These results are in keeping with studies on medical error in other specialities 26 whereby identifying latent failures in otherwise successful procedures enhances risk reduction.

In addition, by preventing minor PSIs, expert teams are able to focus their time and attention on more significant issues such as technical performance, team leadership, and managing unexpected complications. This study shows that PSIs occur across medical, surgical, and nursing specialities as well as during procedures performed by experts and trainees. Targeted training therefore needs to encompass all endoscopists to improve quality and patient safety. Considering the frequency of PSIs across themes, oxygen-monitoring errors occurred most frequently with a similar proportion of mild, intermediate and severe PSIs within this group.

There were no acute hypoxic events related to these PSIs, but this category had the highest number of severe PSIs, underscoring that basic monitoring of oxygen saturations remains an under-utilized safety opportunity with further measures required to ensure adherence to established guidance on safe sedation and oxygen monitoring Sedation practices and guidance vary internationally with conscious and deep sedation options for certain patients and procedures 30 , and sedation administration and monitoring by nurses, endoscopists or dedicated anesthetists.

Anesthetic support would enhance sedation safety, but because it is not universally available, sedation selection, administration, titration, and monitoring are key safety issues for the endoscopist to be aware of and to consciously check. PSIs related to non-technical skills were the next most prevalent group, followed by distractors and time management-related PSIs. Endoscopy non-technical skills training, although feasible 31 and considered important 32 , is not yet explicitly formalized within existing training programs, accreditation processes or quality assurance measures.

This is increasingly recognized as an important component of high-quality practice within screening colonoscopy, for example, 33 and would be a mechanism to address PSIs related to poor non-technical skills and teamwork.


These included patient misidentification and wrong procedure colonoscopy instead of flexible sigmoidoscopy both occurring in a single patient. This PSI would be perceived to be more consequential if a percutaneous endoscopic gastrostomy PEG had been inserted instead of an esophago-gastro duodenoscopy OGD , for example, yet the systemic latent failures whereby both these errors occur is the same.

In line with international recommendations 34 , identification of error was used primarily to construct local solutions to patient safety concerns. Our study findings were fed back to the entire unit where the observations took place, and precipitated several actions to ensure that lessons were learned. Clearly optimizing patient management is key and more likely to occur when the PSI is considered to be severe or to require further corrective action. Additional measures included trainee debriefing by the clinical lead for endoscopy following a difficult list, introduction of an endoscopy safety checklist 35 to ensure essential baseline checks are re-confirmed by the team in the room undertaking the procedure, and adoption of error analysis tools such as the London Protocol 36 to educate multi-disciplinary gastroenterology teams more widely through governance meetings.

Limitations of this study include no long-term follow up data on patient outcomes.

Advanced Digestive Endoscopy: Practice and Safety

Similarly, it is difficult to demonstrate causality between PSIs and negative patient outcomes due to a number of confounding factors. This study was a single-center experience, which raises questions about the generalizability of the results. Lastly, the Hawthorne effect 37 may actually have reduced errors, as endoscopy teams may have been more careful knowing that they were being observed.

This study is the first attempt, to our knowledge, to prospectively identify and analyze a broad range of patient safety incidents across gastrointestinal endoscopic procedures. While many errors were without immediate serious consequence, they represent latent failures and thus provide a golden opportunity to intervene proactively.

By documenting, understanding, responding to and avoiding endoscopy error we have an opportunity to further improve endoscopy practice and believe this should be incorporated into existing quality assurance mechanisms for individual endoscopists and endoscopy units. Further work will address the question as to whether patient safety incidents in endoscopy can be reduced by implementing an endoscopy safety checklist. The long-term goal should focus on accurate, relevant and transparent endoscopy patient safety incident reporting at an individual, unit and national level.

Cotton Peter B. (ed.) Advanced Digestive Endoscopy: Practice and Safety

The authors thank the doctors, nurses and patients at the Wolfson Unit for Endoscopy at St. Mark's Hospital for providing permission to observe their endoscopic procedures.

Competing interests NS is the director of London Safety and Training Solutions Ltd, which provides safety and team training and advisory services on a consultancy basis. Any event that could have had an adverse patient consequence but did not and was indistinguishable from a complete full-blown AE in all but outcome. Adapted from Clavien Dindo Classification for Surgery: Defined as any significant deviation from the normal postoperative course that may or may not require intervention.


Unintended patient injury caused by medical management rather than the underlying disease resulting in measurable disability, prolonged hospitalisation or both. These have been defined for endoscopy and include communication and teamwork, situation awareness, judgement and decision-making and leadership skills.

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Published online Nov Received May 25; Accepted Sep 9. This article has been cited by other articles in PMC. Introduction A plethora of evidence supports the premise that the incidence of iatrogenic harm is significant 1 2. Open in a separate window. Non-technical skills 5 27 and training. Patient safety incident categorization by theme and severity. Discussion To the best of our knowledge, this is the first study to use standardized methodology to prospectively evaluate within the gastrointestinal endoscopy suite. Conclusion This study is the first attempt, to our knowledge, to prospectively identify and analyze a broad range of patient safety incidents across gastrointestinal endoscopic procedures.

Advanced Digestive Endoscopy: Practice and Safety

Acknowledgements The authors thank the doctors, nurses and patients at the Wolfson Unit for Endoscopy at St. The incidence and nature of in-hospital adverse events: The book includes information and guidelines for all aspects of practice management relating to endoscopy. It provides a practical manual on how to perform techniques in the most safe and effective ways to reduce complications. It also contains techniques for screening, diagnosis, treatment and follow-up from THE leading international names. Overview - Peter Cotton.

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Peterson and Beverley Ott. Vargo 'Comment' by Duncan Bell. Endoscopic Equipment - Greg Ginsberg. Digital Documentation in Endoscopy - Lars Aabakken. He has been active in many National and Internationalorganizations, and has given invited lectures and demonstrations inmore than 50 countries. He helped form the British Society forDigestive Endoscopy, and served the British Society ofGastroenterology as its vice president and treasurer.

His bibliography includes over publications, including morethan original contributions in peer reviewed journals, and 8books. In recent years Dr Cotton has become interested and activeparticularly in quality issues in endoscopy, including objectiveassessment of performance, benchmarking and report cards.