Table 2

Learning points from cases, split by individual, team and service-specific issues

Case 1Trainee endoscopists should not perform procedures unsupervised if they are not JAG certified—this puts the patient and trainee at increased risk of an adverse event.
Recognising when a task is beyond your skill set and acting on it is key to patient safety.
Having good situational awareness and effective communication with the nursing team may prevent ‘tunnel vision’ at stressful times and may avert a crisis.
Nursing staff should be empowered to challenge endoscopists if they feel patient safety is compromised and seek further support if necessary.
Using checklists enhances the likelihood of adhering to basic patient safety measures particularly at times of stress when cognitive workload is increased.
A team briefing would have identified the overbooked complex list and alternative measures put into place proactively.
System errors are prevalent in the organisation of procedures and the clinician is often the inheritor of risk. An overbooked list and parallel on-call commitment should be escalated with the endoscopy clinical lead.
Case 2If opiate and benzodiazepine sedation are used together should be at least a 1 min gap between administration.
Aspiration risk increases with concomitant use of lignocaine throat spray and intravenous sedatives. Consider avoiding this in high-risk patients.
Consider single-agent intravenous sedation in elderly and cachectic patients. Combination of fentanyl and midazolam even in low doses may cause profound respiratory depression and sedation in these patients.
Oesophageal obstruction is associated with a high risk of aspiration. Seek anaesthetic review and support even if patients may not be for resuscitation or intubation.
Careful consent for high-risk procedures and/or patients with advanced comorbidity. If possible, include family and next of kin in discussions.
Equipment, drug stock and administration devices should be checked prior to every case.
Careful review of the drug chart should be performed prior to endoscopy and form part of the team briefing/checklist.
Reversal agents with the relevant drawing up equipment should be kept together and be easily accessible.
Case 3The term ‘trainee’ maybe confusing and misleading to patients and we ought to consider other terms in view of competence.Documentation by the team involved is crucial following an adverse event. Those involved should write contemporaneous notes so that if there is an investigation or a complaint at a later date there is a full record of what happened.Following an adverse event or complication, communication with the patient should continue until the issue is fully resolved. The patient should be invited to discuss what happened as soon as they have recovered.
Patients should be offered a copy of their consent form to keep a record of benefits, risks and discussions around a procedure.
Case 4The new assistant may not have understood the instruction to inflate to the desired limit as a result of ineffective handover and/or inexperience with equipment.
It is good practice for the endoscopy assistant to repeat instructions back to the endoscopist for confirmation. This reflects the concept of ‘closed-loop communication’ where the ‘sender’ of messages ensures that they are conveyed and understood by ‘recipients’.
Team focus can be impaired by staff swapping into procedures or handing over while it is in process. Ideally, staff should not swap during advanced, therapeutic endoscopic procedures. If it is necessary, the endoscopist should be warned at an appropriate moment, and asked to confirm that they are happy for this to go ahead. The incoming assistant must have time to be briefed on the stage of the procedure and what the therapeutic intention is. Two-stage balloons may carry an inherent risk and services should make enquiries into ordering balloons with fixed diameter syringes so that accidental overinflation cannot occur.
Case 5Following rectal intubation, the perineum should be inspected to ensure that the correct orifice has been used prior to further progress being made and/or biopsies being taken.
Avoid the practice of freezing the endoscopic image while the scope is being inserted.
Use direct endoscopic views as well as direct perineal examination to guide insertion.
Retrieving discarded items from a sharps bin should never be undertaken and is a serious hazard.
Use the expertise of the endoscopy nurses if an unusual view is obtained.
Ensuring the procedure room is well lit prior to the insertion of the endoscope, to ensure the perineum is visualised.
Maintain clear communication between team members in relation to the management of biopsies.
Use the team brief at the start of the list to familiarise team members with new endoscopists.
Prompt and effective communication is necessary at the time of an incident, including full duty of candour, as was done in this case. There should be appropriate escalation and follow-up by senior clinicians of relevant specialties with subsequent reassurance if no lasting harm has been caused by the incident.
  • JAG, Joint Advisory Group on Gastrointestinal Endoscopy.