Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.

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.

This study of more than 45,000 colonoscopies found that 4.7 serious adverse events occurred per 1000 screening colonoscopies. Advanced age and the need for polyp removal were associated with increased risk of adverse events.

This commentary applied Joint Commission patient safety standards to the endoscopy care setting and suggests that audits can improve staff engagement in safety work.

An automated surveillance system within an existing electronic medical record detected many more post-procedural adverse events than standard voluntary reporting.