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‘Case of the month’: a novel way to learn from endoscopy-related patient safety incidents
  1. Srivathsan Ravindran1,2,
  2. Manmeet Matharoo3,
  3. Tim Shaw1,
  4. Emma Robinson1,
  5. Matthew Choy4,5,
  6. Philip Berry6,
  7. John O'Donohue7,
  8. Chris J Healey1,8,
  9. Mark Coleman1,9,
  10. Siwan Thomas-Gibson2,3
  1. 1 Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
  2. 2 Department of Surgery and Cancer, Imperial College London, London, UK
  3. 3 Wolfson Endoscopy Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
  4. 4 Department of Gastroenterology, Austin Health, Heidelberg, Victoria, Australia
  5. 5 Department of Medicine, Austin Academic Centre, The University of Melbourne, Heidelberg, Victoria, Australia
  6. 6 Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
  7. 7 Department of Gastroenterology, University Hospital Lewisham, London, London, UK
  8. 8 Gastroenterology and Hepatology Services, Airedale NHS Foundation Trust, Keighley, UK
  9. 9 Department of Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
  1. Correspondence to Dr Srivathsan Ravindran, Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London NW1 4LE, UK; sravindran1{at}


Patient safety incidents (PSIs) are unintended or unexpected incidents which can or do lead to patient harm. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) acknowledges that PSIs should be reviewed by endoscopy services and learning shared among staff. It is recognised that more could be done to promote shared learning as outlined by the JAG ‘Improving Safety and Reducing Error in Endoscopy’ strategy. The ‘Case of the month’ series aims to provide a broad selection of cases and subsequent learning that can be shared among services and their workforce. This review focuses on five case vignettes that highlight a variety of PSIs in endoscopy. A structured approach, based on incident analysis methodology, is applied to each case to categorise PSIs and develop learning points. Learning is directed toward the individual, team and healthcare organisation. A selection of methods to disseminate learning at local, regional and national levels are also described.

  • endoscopy

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  • Contributors SR wrote the manuscript with editorial oversight from ST-G, MM, MC and CJH. All authors contributed to case summaries and learning points. SR, MM and ST-G conducted the incident categorisation and analysis. ER designed infographics. All authors reviewed the final manuscript prior to submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SR, CJH, MC and ST-G hold or have held clinical positions at the Joint Advisory Group on GI endoscopy.

  • Provenance and peer review Not commissioned; externally peer reviewed.