PT  - JOURNAL ARTICLE
AU  - Srivathsan Ravindran
AU  - Manmeet Matharoo
AU  - Tim Shaw
AU  - Emma Robinson
AU  - Matthew Choy
AU  - Philip Berry
AU  - John O'Donohue
AU  - Chris J Healey
AU  - Mark Coleman
AU  - Siwan Thomas-Gibson
TI  - ‘Case of the month’: a novel way to learn from endoscopy-related patient safety incidents
AID  - 10.1136/flgastro-2020-101600
DP  - 2021 Dec 01
TA  - Frontline Gastroenterology
PG  - 636--643
VI  - 12
IP  - 7
4099  - http://fg.bmj.com/content/12/7/636.short
4100  - http://fg.bmj.com/content/12/7/636.full
SO  - Frontline Gastroenterol2021 Dec 01; 12
AB  - 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.