Introduction Medical error is common and causes significant morbidity and mortality.¹ A significant proportion of adverse events are deemed to be preventable and often arise from multiple systems failures as per Reason's “Swiss Cheese” model. The DOH's “never events” (NE) are defined as serious but preventable patient safety incidents (PSI). These include overdose of midazolam during conscious sedation & failure to monitor/respond to oxygen saturations, which are anecdotally common. NHS Trusts are incentivised to prevent NEs as serious financial penalties are incurred. To further improve quality and safety in Endoscopy, a structured analysis of current safety pitfalls is relevant, particularly in the context of the NHS Bowel Cancer Screening programme, where increasing numbers of asymptomatic individuals will undergo an endoscopic procedure.

Methods All types of GI endoscopic procedures were prospectively observed in a single tertiary endoscopy unit by a Gastroenterologist trained in patient safety and behavioural observation. A representative sample of Endoscopists by specialty (physician, surgeon & nurse) & grade (trainee, consultant & BCS Endoscopist) were recruited. The procedures were observed from within the endoscopy room or via AV live link with a tri-split screen (team, luminal and scope guide views). The medical record, nursing notes & endoscopy reports were also reviewed. All PSIs (defined as near misses, adverse events or NEs) were qualitatively recorded and subsequently categorised by expert consensus for type (clinical, process or human error) & severity (1=Mild 2=Moderate 3=Severe).

Results 90 procedures (22 lists, 16 Endoscopists) were analysed. A total of 41 PSIs were identified (PSI rate = 45%). 51% (n=21) of these were categorised as “severe” & 24% (n=10) had the potential to be full NEs. The Abstract OC-012 table 1 illustrates some examples of severe PSIs:

Conclusion This study is the first attempt to identify and categorise relevant Endoscopy PSIs in a structured fashion. Findings indicate that PSIs may be more common than previously thought. While PSIs in this study did not incur serious consequences for patients, they represent a latent risk & should be addressed. The focus for adverse events should shift from that of “reporting” to “understanding” the multifaceted reasons why a PSI occurred. Near misses represent a golden opportunity to intervene proactively. Further studies will examine the root cause for these errors & whether PSIs & never events can be reduced by implementing and validating an Endoscopy Safety Checklist.

Competing interests M Matharoo grant/research support from: The NHS BCS research programme, conflict with: the freemasons grand charity, A Haycock: None declared, N Sevdalis: None declared, S Thomas-Gibson: None declared.

Reference 1. Vincent, et al. Adverse events in British Hospitals: preliminary retrospective record review. BMJ 2001;322.