Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS).

BACKGROUND AND AIMS Despite advances in understanding and reducing risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify non-procedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement. METHODS Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy. RESULTS From 2017 - 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales. Of these, 539 (45.6%) were nPSIs. Five categories accounted for over 80% of all incidents with 'follow up and surveillance' being the largest (23.4% of all nPSIs). 487 human factors codes were identified from free-text incident reports. Decision-based errors were the most common act prior to PSI occurrence. Preconditions to incident focussed on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety are made in response to our findings. CONCLUSIONS This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.