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 Srivathsan Ravindran A1 Manmeet Matharoo A1 Tim Shaw A1 Emma Robinson A1 Matthew Choy A1 Philip Berry A1 John O'Donohue A1 Chris J Healey A1 Mark Coleman A1 Siwan Thomas-Gibson 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.