National root-cause analysis of 1724 post-colonoscopy colorectal cancers demonstrates avoidable harm

Nicholas E Burr; David Beaton; Nigel Trudgill; Andrew Lee; Tameera Rahman; Sean McPhail; Natasha Wood; Matthew David Rutter; Roland Valori; Eva Judith Ann Morris

doi:10.1055/a-2681-5642

Endoscopy, Table of Contents

Endoscopy
DOI: 10.1055/a-2681-5642

Original article

National root-cause analysis of 1724 post-colonoscopy colorectal cancers demonstrates avoidable harm

Nicholas E Burr

¹Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom of Great Britain and Northern Ireland

²Faculty of Medicine and health, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland

,

David Beaton

³Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Cramlington, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN3762)

,

Nigel Trudgill

⁴DEPARTMENT OF GASTROENTEROLOGY, SANDWELL GENERAL HOSPITAL, WEST BROMWICH, United Kingdom of Great Britain and Northern Ireland

,

Andrew Lee

⁵Gastroenterology, Toowoomba Hospital, Toowoomba, Australia (Ringgold ID: RIN67573)

,

Tameera Rahman

⁶Data Team, Health Data Insight, Cambridge, United Kingdom of Great Britain and Northern Ireland

,

Sean McPhail

⁷NCRAS, National Disease Registration Service, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN496847)

,

Natasha Wood

⁸Management, Health Data Insight, Cambridge, United Kingdom of Great Britain and Northern Ireland

,

Matthew David Rutter

⁹Gastroenterology, University Hospital of North Tees, Stockton on Tees, United Kingdom of Great Britain and Northern Ireland

¹⁰Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN12186)

,

Roland Valori

¹¹Gastroenterology, Gloucester, Gloucester, United Kingdom of Great Britain and Northern Ireland

,

Eva Judith Ann Morris

¹²Nuffield Department of Population Health, University of Oxford Big Data Institute, Oxford, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN575096)

› Author Affiliations

Abstract

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Background and study aims Post-colonoscopy colorectal cancer (PCCRC) represents a potential missed opportunity to diagnose or prevent colorectal cancer. This study aimed to create a standardised, nationwide audit system to determine why PCCRCs occur and to generate evidence to prevent them. Patients and methods PCCRCs occurring 6–48 months after a colonoscopy were identified from English national datasets and uploaded to a secure portal. The portal contained case review form based on World Endoscopy Organisation (WEO) recommendations for PCCRC review. 126 NHS colonoscopy providers were asked to review up to 25 PCCRCs. The data were analysed to investigate the characteristics of and reasons for PCCRC. Results Of 2,859 PCCRCs, 1,724 (60%) were reviewed. Colonoscopies were mostly performed for symptoms (59%) or surveillance (26%). PCCRCs were more common at the hepatic and splenic flexures and transverse colon than in the detected CRCs. PCCRC WEO categorisations were: possible missed lesion, examination adequate 68%; possible missed lesion, examination inadequate 18%; detected lesion, not resected 9%; and likely incompletely resected lesion 5%. 69% of PCCRCs were avoidable and 44% led to harm, including premature death in 8%. Non-procedural reasons contributed to 27% of PCCRCs: patient factors, 10%; clinical decision-making, 10%; and administrative factors, 7%. Conclusions This is the largest detailed PCCRC review to date. The majority of PCCRCs were avoidable and caused significant harm. This study clarifies the causes of diagnostic delays and highlights high-risk areas of the colon and high-risk patients, and what needs to be done to reduce PCCRC in the future.

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