RT Journal Article
SR Electronic
T1 ‘Case of the month’: a novel way to learn from endoscopy-related patient safety incidents
JF Frontline Gastroenterology
JO Frontline Gastroenterol
FD BMJ Publishing Group Ltd
SP 636
OP 643
DO 10.1136/flgastro-2020-101600
VO 12
IS 7
A1 Ravindran, Srivathsan
A1 Matharoo, Manmeet
A1 Shaw, Tim
A1 Robinson, Emma
A1 Choy, Matthew
A1 Berry, Philip
A1 O'Donohue, John
A1 Healey, Chris J
A1 Coleman, Mark
A1 Thomas-Gibson, Siwan
YR 2021
UL http://fg.bmj.com/content/12/7/636.abstract
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.