ERRORS IN ENDOSCOPY, SCOPE TO IMPROVE? AN ANALYSIS OF NON-TECHNICAL SKILLS AND SAFETY CHECKS IN ENDOSCOPY

摘要

Introduction Existing evidence shows that many medical errors are avoidable and a systematic approach using safety checks such as the WHO Surgical Safety Checklist can reduce adverse events.1 Research within high-risk industries has illustrated that errors with significant impact on safety often relate to non-technical skills (NTS) rather than technical ability. By focusing on the key NTS in Endoscopy, we hypothesise that team function2 will be enhanced, patient safety improved and errors reduced.Methods Current safety practices in Endoscopy were evaluated prospectively via (1) Assessment of current safety checks and (2) Analysis of safety enhancing NTS (ie, behaviours), based on a pilot study. Behaviours deemed to be “safety checks” (SC) that impact positively on patient care were determined by expert consensus. Endoscopists were observed and their checking behaviours assessed by two independent clinical observers: (1–4 scale, 4 = “gold standard” SC of “cross checking” with a colleague, 1= no discernible attempt to perform an SC). Endoscopists NTS were assessed quantitatively (1–4 scale) using a validated framework.3 In addition any errors, near misses or adverse events (AE) were qualitatively recorded for each procedure.Results 22 lists were observed and 90 procedures analysed from a representative sample of 16 Endoscopists. In total 1218 opportunities to perform a safety check were identified. The “gold standard check” was only performed in 9% of instances. In 37% of episodes no check was completed. Endoscopists and nurses performed similar checks separately, often without communication. ENTS scores varied, (mode=3, min=1 max=4). Endoscopists scoring higher on NTS were more likely to perform safety checks (correlation coefficient r=0.82 p≤0.001). 41 safety incidents were observed and 27% occurred in the lists where the Endoscopist scored an NTS of 1 or 2 and 0% occurred in those with an NTS of 4.Conclusion This study demonstrates wide variability in safety checks and non-technical skills in Endoscopy. There appears to be a relationship between robust safety checks and good NTS. Further research should focus on the relationship between technical (DOPS) and non-technical (ENTS) skills and whether training in NTS for Endoscopists can reduce adverse events and improve their safety behaviour.