Minoli G, Borsato P, Colombo E, Bortoli A, Casetti T, de Pretis G, Ferraris L, Lorenzini I, Meggio A, Meroni R, Piazzi L, Terruzzi V. Errors and near misses in digestive endoscopy units.
Dig Liver Dis 2012;
44:914-8. [PMID:
22809959 DOI:
10.1016/j.dld.2012.06.009]
[Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/15/2012] [Accepted: 06/17/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND
Not much is known about errors and near misses in digestive endoscopy.
AIMS
To verify whether an incident report, with certain facilitating features, gives useful information about unintended events, only excluding errors in medical diagnosis.
METHOD
Nine endoscopy units took part in this cross sectional, prospective, multicentre study which lasted for two weeks. Members of the staff were required to report any unintended, potentially dangerous event observed during the daily work. A form was provided with a list of "reminders" and facilitators were appointed to help. The main outcome measurements were type of event, causes, corrective interventions, stage of occurrence in the workflow and qualification of the reporters.
RESULTS
A total of 232 errors were reported (two were not related to endoscopy). The remaining 230 amount to 10.3% of 2239 procedures; 66 (29%) were considered errors with consequences, 164 (71%) "near misses". There were 150 pre-operative errors (65%), 22 operative (10%) and 58 post-operative (25%). Corrective interventions were provided for 60 cases of errors and 119 near misses. Most of the events were reported by the nurses (106 out of 232, 46%).
CONCLUSIONS
Short-term incident reporting focusing on near misses, using forms with lists of "reminders", and the help of a facilitator, can give useful information on errors and near misses in digestive endoscopy.
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