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PSNet: Patient Safety Network
Journal Article

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

Soncrant C, Mills PD, Neily J, et al. J of Patient Saf. 2020;16.

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.