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PWE-024 The colorectal cancer mdt: how many errors occur, do they matter and can they be averted?
  1. MK Matharoo1,
  2. R Baldwin2,
  3. A Haycock1,
  4. J Jenkins3,
  5. D Burling2,
  6. N Sevdalis4,
  7. S Thomas-Gibson1
  1. 1Endoscopy
  2. 2Radiology
  3. 3Surgery, St. Mark–s Hospital
  4. 4Patient Safety, Imperial College, London, UK


Introduction The colorectal cancer multidisciplinary team (CRC MDT) provides a common pathway for patients from Bowel Cancer Screening (BCS), symptomatic (SYM), 2-week wait (2WW) and tertiary (TER) pathways. These pathways are complex and variable and hence error prone. Improved endoscopic techniques have transformed CRC management but little is known about improvements required for the MDT. Enhancing MDT quality by addressing errors can raise quality assurance at the bridge between diagnostic and therapeutic pathways. Objectives: To prospectively record Patient Safety Incidents (PSIs) identified at CRC MDT across different patient pathways.

Method Two independent clinical observers prospectively evaluated CRC MDTs in real time. Patients were subcategorised by clinical pathway: BCS, 2WW, SYM and TER. PSIs were noted qualitatively for each patient and subsequently categorised. PSIs were defined as near misses, adverse events and sub-optimal clinical processes negatively impacting the patient’s cancer care.

Results 412 MDT patient discussions (SYM n = 165, 2WW n = 97, TER n = 97 BCS n = 53) over 27 meetings were prospectively analysed. Medical notes were unavailable for 73 (21%) patients. 146 PSIs were identified: SYM n = 62 (42%), 2WW n = 37 (25%), TER n = 31 (21%), BCS n = 16 (11%). There was a trend towards more errors in the SYM group and fewer in BCS, although there was no significant difference between groups (p = 0.39). Table 1illustrates examples of severe PSIs. Many PSIs related to miscommunication, incomplete clinical data and poor non-technical skills such as leadership and inclusive team discussion. Although many PSIs did not have direct patient consequences they represent areas for improvement to avoid future significant errors.

Conclusion Multiple errors were observed across the CRC MDT irrespective of patient subgroups. We propose a minimum patient data set and MDT team training in non-technical skills. Further work is underway to categorise PSIs by expert consensus, identify strategies to prevent avoidable error and ensure accountability for correcting errors. Examining PSIs arising outside the MDT provides a valuable opportunity to correct errors in other parts of the cancer pathway that may otherwise go un-noticed.

Disclosure of interest None Declared.

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