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'Case of the month': a novel way to learn from endoscopy-related patient safety incidents
- Source :
- Frontline Gastroenterol
- Publication Year :
- 2020
-
Abstract
- Patient safety incidents (PSIs) are unintended or unexpected incidents which can or do lead to patient harm. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) acknowledges that PSIs should be reviewed by endoscopy services and learning shared among staff. It is recognised that more could be done to promote shared learning as outlined by the JAG ‘Improving Safety and Reducing Error in Endoscopy’ strategy. The ‘Case of the month’ series aims to provide a broad selection of cases and subsequent learning that can be shared among services and their workforce. This review focuses on five case vignettes that highlight a variety of PSIs in endoscopy. A structured approach, based on incident analysis methodology, is applied to each case to categorise PSIs and develop learning points. Learning is directed toward the individual, team and healthcare organisation. A selection of methods to disseminate learning at local, regional and national levels are also described.
- Subjects :
- Hepatology
medicine.diagnostic_test
business.industry
Shared learning
Gastroenterology
Case vignette
Endoscopy
medicine.disease
Variety (cybernetics)
03 medical and health sciences
Patient safety
0302 clinical medicine
Workforce
Health care
Medicine
030211 gastroenterology & hepatology
030212 general & internal medicine
Medical emergency
business
Gastrointestinal endoscopy
Subjects
Details
- ISSN :
- 20414137
- Volume :
- 12
- Issue :
- 7
- Database :
- OpenAIRE
- Journal :
- Frontline gastroenterology
- Accession number :
- edsair.doi.dedup.....759167ca694b3c66c3db90a7fd2e352b