Endoscopy 2022; 54(S 01): S44-S45
DOI: 10.1055/s-0042-1744650
Abstracts | ESGE Days 2022
ESGE Days 2022 Oral presentations
16:30–17:30 Thursday, 28 April 2022 Club H. SAFETY FIRST !

SAFETY INCIDENTS IN ENDOSCOPY – A HUMAN FACTORS ANALYSIS

S. Ravindran
1   Joint Advisory Group on Gastrointestinal Endoscopy, London, United Kingdom
2   St Mark’s Academic Institute, Wolfson Unit for Endoscopy, London, United Kingdom
3   Imperial College London, Surgery and Cancer, London, United Kingdom
,
M. Matharoo
2   St Mark’s Academic Institute, Wolfson Unit for Endoscopy, London, United Kingdom
,
C. Healey
1   Joint Advisory Group on Gastrointestinal Endoscopy, London, United Kingdom
,
M. Coleman
1   Joint Advisory Group on Gastrointestinal Endoscopy, London, United Kingdom
,
H. Ashrafian
3   Imperial College London, Surgery and Cancer, London, United Kingdom
,
A. Darzi
3   Imperial College London, Surgery and Cancer, London, United Kingdom
,
S. Thomas-Gibson
2   St Mark’s Academic Institute, Wolfson Unit for Endoscopy, London, United Kingdom
4   Imperial College London, Metabolism, Digestion and Reproduction, London, United Kingdom
› Author Affiliations
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Aims Outside of procedural adverse events and complications, there is little understanding of wider patient safety incidents (PSIs) in endoscopy. The aim of this study was to quantify endoscopy PSIs and identify their contributory human factors utilising a national data set.

Methods Data were extracted from the National Reporting and Learning System (NRLS) which records staff-reported safety incidents in England and Wales. Two independent coders with backgrounds in safety and human factors analysis coded data using a hybrid thematic analysis approach. Pareto analysis was utilised to ascertain the causes of the top 80% of incidents and the Human Factors Analysis and Classification System (HFACS) was applied to code contributory factors.

Results Over the period 2017-2019, 1811 endoscopy-related PSIs were identified, of which 629 were procedural adverse events (pAEs; directly related to procedure), 539 were non-procedural adverse events (nAEs; any incident not directly related to a procedure) and 16 were ‘never’ events. Inter-coder reliability was substantial with a kappa of 0.77. A total of 842 human factors codes were identified from available data across four levels: acts, preconditions, supervision and organisational influences. Decision-based errors were the most common acts (>40%) across categories. Patient factors were significant contributors in pAEs (74.5%) and co-ordination, communication (33.5 – 66.7%) and situational (27.1%) factors were key contributory factors in nAEs and never events.

Table 1

Procedural adverse events

Non-procedural adverse events

Never events

Distribution

629/1181 (53.3%)

539/1181 (45.6%)

16/1181 (1.4%)

Categories (n,%)

  • Instrumental (312, 49.8%)

  • Bleeding (94. 15%)

  • Cardiovascular (39, 6.2%)

  • Pulmonary (27, 4.3%)

  • Pancreatitis (25, 4.0%)

  • Pain (23, 3.7%)

  • Drug reaction (17, 2.7%)

  • Infection (15, 2.4%)

  • Integument (14, 2.2%)

  • Thromboembolic (13, 2.1%)

  • Other (48, 7.7%)

  • Follow up & surveillance (126, 23.4%)

  • Access & booking (106, 19.7%)

  • Quality (93, 17.3%)

  • Specimens/histopathology (61, 11.3%)

  • Peri-endoscopy care (40, 7.4%)

  • Staffing, environment, infrastructure (28, 5.2%)

  • Patient harm or injury (25, 4.6%)

  • Communication (20, 3.7%)

  • Equipment (18, 3.3%)

  • Documentation (8, 1.5%)

  • Consent (8, 1.5%)

  • Decontamination (6, 1.1%)

  • Wrong patient (10, 62.5%

  • Wrong site (6, 37.5%

Reported degree of harm (n,%)

  • Moderate (484, 77.2%)

  • Severe (62, 10.2%)

  • Death (79, 12.6%)

  • Moderate (390, 72.4%)

  • Severe (131, 24.3%)

  • Death (18, 3.3%)

  • Moderate (14, 87.5%)

  • Severe (2, 12.5%)

Contributory factors (HFACS)

Level 1: Decision-based errors (43.6%) Level 2: Patient factors (74.5%) Co-ordination and communication factors (16.5%)

Level 1: Decision-based errors (51.8%) Routine non-concordance (23.8%) Level 2: Communication (33.5%) Situational factors (27.1%) Level 3: Planning (58.8%)Level 4: Organisational processes (42.3%)

Level 1: Decision-based errors (58.3%) Skill-based errors (41.7%)Level 2: Co-ordination and communication factors (66.7%)
Zoom Image
Fig. 1

Conclusions This is the first overview of national-level endoscopy safety incident data and demonstrates the role human factors play in PSI development. These findings should inform patient safety improvement strategies in endoscopy.



Publication History

Article published online:
14 April 2022

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