Improving safety and quality in endoscopy patient pathways

Patient safety is a key priority as it is acknowledged that medical error is common, multifactorial and often avoidable. Gastrointestinal endoscopy is increasingly a therapeutic procedure not without risk. Current training in endoscopy focuses on technical aspects with no formal recognition of non-technical skills such as communication, leadership, decision-making and teamwork. Error analysis in other medical specialties suggests that non-technical skills are often implicated. Recognition, understanding and training in endoscopic non-technical skills may enhance team-working skills and contribute towards patient safety. The overarching aim of this thesis is to understand the breadth of errors that occur in endoscopy and to objectively evaluate non-technical skills and teamwork in endoscopy and the colorectal cancer multi-disciplinary team. Based on this, measures to mitigate error enhance teamwork and non-technical skills will be implemented and evaluated. Part A of this thesis focuses on identifying and defining problems impacting patient safety in endoscopy. The introductory chapter details the emergence of patient safety and quality within healthcare and contextualises the importance of these concepts for endoscopy. In Chapter 2 endoscopy team members’ attitudes towards patient safety in endoscopy are explored coupled with a prospective evaluation of the frequency, type and severity of patient safety incidents. Teamwork processes are examined and presented in Chapters 3 and 4 by scientifically evaluating safety checks, technical and non-technical skill by endoscopy teams conducting elective and emergency procedures respectively. Chapter 5 evaluates the extended endoscopy pathway by measuring performance in the colorectal cancer MDT by assessing teamwork, decision-making and errors across key patient groups. Educational strategies and quality improvement interventions are implemented to support patient safety beyond endoscopy. In part B of this thesis specific interventions to enhance the safety and quality issues identified in part A are presented. Chapter 6 aims to determine the feasibility and effectiveness of a novel multi-disciplinary team training intervention for bowel cancer screening teams by targeting non-technical skills, error analysis and enhanced team performance strategies. Finally in Chapter 7 an endoscopy safety checklist is proposed and implemented into clinical practice. The checklist was prospectively evaluated in detail to examine effects on safety checks, patient safety incidents, technical and non-technical skills. In summary, this thesis serves to identify clinically transferable approaches to improve patient safety within endoscopy.Open Acces

A prospective study of patient safety incidents in gastrointestinal endoscopy

Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included. PSIs were defined as any safety issue that had the potential to or directly adversely affected patient care: PSIs included near misses, complications, adverse events and “never events”. PSIs were reviewed by an expert panel and categorized for severity and nature via expert consensus. Results One hundred and forty procedures (92 diagnostic, 48 therapeutic) over 37 lists (experienced operators n = 25, trainees n = 12) were analyzed. One hundred forty PSIs were identified (median 1 per procedure, range 0 – 7). Eighty-six PSIs (61 %) occurred in 48 therapeutic procedures. Zero PSIs were detected in 13 diagnostic procedures. 21 (15 %) PSIs were categorized as severe and 12 (9 %) had the potential to be “never events,” including patient misidentification and wrong procedure. Forty PSIs (28 %) were of intermediate severity and 78 (56 %) were minor. Oxygen monitoring PSIs occurred most frequently. Conclusion This is the first study documenting the range and frequency of PSIs in endoscopy. Although many errors are minor without immediate consequence, further work should identify whether prevention of such recurrent errors affects the incidence of severe errors, thus improving safety and quality

Endoscopic non-technical skills team training:The next step in quality assurance of endoscopy training

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. METHODS: A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day’s training utilising real clinical examples. Pre and post-course evaluation comprised participants’ patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. RESULTS: Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. CONCLUSION: A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams’ knowledge and safety attitudes

The endoscopy safety checklist:A longitudinal study of factors affecting compliance in a tertiary referral centre within the United Kingdom

Gastrointestinal endoscopy is a widely used diagnostic and therapeutic procedure both within the United Kingdom and worldwide. With an increasingly older population the potential for complications is increased. The Wolfson Unit for Endoscopy at St. Mark's Hospital in London is a tertiary referral centre, which conducts over 14,000 endoscopic procedures annually. However, despite this high throughput, our baseline observations were that the procedure for safety checks was highly variable. Over a seven-day period we conducted a questionnaire-based survey to all staff members involved with endoscopy within our unit. We found that there was little consensus between team members, both in terms of essential safety checks and designating responsibility for the checks. A panel of experts was convened in order to devise a safety checklist and a strategy for increasing compliance with the checklist among all staff members. Using a combination of electronic and physical reminders and incentives, we found that there was a significant increase in completed checklist (53% to 66%, p = 0.021) and decrease in the number of checklists left blank post intervention (10% to 2%, p=0.03). We believe that post implementation validation of safety checklists is an important method to ensure their proper use

Development, validation, and results of a national endoscopy safety attitudes questionnaire (Endo-SAQ)

Background and study aims Safety attitudes are linked to patient outcomes. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) identifies the need to improve our understanding of safety culture in endoscopy. We describe the development and validation of the Endo-SAQ (endoscopy safety attitudes questionnaire) and the results of a national survey of staff attitudes. Methods Questions from the original SAQ were adapted to reflect endoscopy-specific content. This was refined by an expert group, followed by a pilot study to assess acceptability. The refined Endo-SAQ (comprising 35 questions across six domains) was disseminated to endoscopy staff across the UK and Ireland. Outcomes were domain scores and the percentage of positive responses (score ≥ 75/100) per domain. Descriptive and comparative analyses were performed. Binary logistic regression identified staff and service factors associated with positive scores. Validity and reliability of Endo-SAQ were assessed through psychometric analysis. Results After expert review, four questions in the preliminary Endo-SAQ were adjusted. 61 participants undertook the pilot study with good acceptability. 453 participants completed the refined Endo-SAQ. There were positive responses in teamwork, safety climate, job satisfaction and working conditions domains. Endoscopists had significantly more positive responses to stress recognition and working conditions than nursing staff. JAG accreditation was associated with positive scores in safety climate and job satisfaction domains. Endo-SAQ met thresholds of construct validity and reliability. Conclusions Endoscopy staff had largely positive safety attitudes scores but there were significant differences across domains and staff. There is evidence for the validity and reliability of Endo-SAQ. Endo-SAQ could complement current measures of patient safety in endoscopy and be used in evaluation and research