Regular monitoring of vital signs is key to early identification of patient deterioration and provision of rapid response. This hospital in Norway determined inconsistent documentation of vital signs could be a barrier to successful implementation of a rapid response system (RRS). During the decade following introduction and refinement of the RRS, the number of completed vital sign sets increased, as did intensive care consultation, another component of RRS. Overall the RSS was associated with a reduction of in-hospital and 30-day mortality rates.

Women often experience misdiagnosis and diagnostic delays due to process failures and implicit bias. This multicenter cohort study including 190 patients found that women were more likely to experience delays in diagnosis and misdiagnosis of inflammatory bowel disease, as compared to men. Researchers found that these inequities in misdiagnosis occurred across all healthcare settings (emergency department, primary care, gastroenterology, and hospital admission).

Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.

TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.

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.

Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.

Teamwork is a key element of safe medical care. This commentary examines teamwork in gastroenterology and offers a developmental framework of high-performing teams. The author spotlights the role of experiential learning and formal educational programs in this setting and notes the importance of psychological safety, trainee observation, and organizational culture.

This large observational study of more than 1.3 million patients who underwent either a colonoscopy or upper endoscopy procedure found that the use of an anesthesia professional did not improve safety outcomes compared with sedation administered by the endoscopist. For lower risk patients undergoing upper endoscopy, there was an increased rate of serious adverse events in cases that involved an anesthesia professional.

This commentary provides a statistical discussion of adverse events in gastroenterology to conclude that some events are unavoidable, even with quality improvement strategies. A related commentary offers counterpoints and suggests that although some adverse events are unavoidable, many are preventable and efforts to improve safety in health care should focus on accountability, systems factors, and preventability of errors.