Errors and near misses in digestive endoscopy units.
BACKGROUND
Not much is known about errors and near misses in digestive endoscopy.


OBJECTIVE
To verify whether an incident report, with certain facilitating features, gives useful information about unintended events, only excluding errors in medical diagnosis.


METHODS
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.
UO di Gastroenterologia, Ospedale Valduce, Como, Italy. giorgio.minoli@gmail.com
Giorgio
G
Minoli
Paolo
P
Borsato
Enrico
E
Colombo
Aurora
A
Bortoli
Tino
T
Casetti
Giovanni
G
de Pretis
Luca
L
Ferraris
Ivano
I
Lorenzini
Alberto
A
Meggio
Rudy
R
Meroni
Lucia
L
Piazzi
Vittorio
V
Terruzzi
D003430:Cross-Sectional Studies; D016145:Endoscopy, Digestive System / Q000706:statistics & numerical data*; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D059035:Perioperative Period / Q000706:statistics & numerical data; D011446:Prospective Studies; D012308:Risk Management / Q000706:statistics & numerical data; D057188:Workflow