Navigating the path to patient safety in endoscopy…going beyond the procedure!

Abstract

Continuous quality improvement and patient safety in gastrointestinal (GI) endoscopy are overarching priorities of endoscopy services. Our patients expect us to provide a safe, standardized, and rigorous approach to the performance of GI endoscopy, especially in this era of increasing procedural complexity. To improve patient safety during endoscopy, measures such as pre-endoscopy checklists are recommended and have been implemented in many endoscopy units around the world [1]. Yet, despite our best efforts, endoscopy procedural adverse events, or "patient safety incidents" (PSIs) occur. However, PSIs that occur before and/or after the endoscopy procedure itself (defined as "nonprocedural patient safety incidents" [nPSIs]) are rarely tracked and documented, and usually not on a nationwide level [2,3].In this issue of Endoscopy, Ravindran and colleagues, using a cross-sectional qualitative study design, extracted and analyzed endoscopy-specific PSIs from the National Reporting and Learning System (NRLS) database [4]. The NRLS database contains records of all reported safety incidents in England and Wales. PSIs were defined as "any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare" [5]. The aim of their study was threefold: within the context of the overall endoscopy service, to characterize nPSIs contributing to "significant harm" (moderate and severe harm, or death); to identify potential contributing human factors; and to identify goals for safety improvement. To achieve these aims, the investigators performed "incident analysis" to identify the factors that contributed to the incident, including human factors, thereby informing the prevention of future nPSIs. Human factors include environmental, organizational, and human characteristics that may influence performance [6].