Patient safety in an endoscopy unit: an observational retrospective analysis of reported incidents

Abstract

Introduction: Patient safety is a serious public health with serious implications on morbidity, mortality, and quality of life of patients, in addition to negatively affecting the public image of healthcare institutions and professionals. It requires further investigation, especially in specialties lacking published data, such as endoscopy.

Objective: To analyze patient safety incidents reported in a gastrointestinal endoscopy unit of a tertiary hospital in southern Brazil.

Methods: This retrospective, cross-sectional study quantitatively described patient safety incidents related to endoscopic procedures. The sample consisted of reports of incidents that occurred from 2015 to 2017. The data were descriptively analysed, and the study was approved by the relevant research ethics committee.

Results: Overall, 42,863 endoscopic procedures were performed and 167 reports were submitted in the period, accounting for a prevalence of incidents of 0.38%. Most incidents did not result in unnecessary harm to patients (76.6%). The most prevalent incidents were those related to patient identification, followed by those related to pathology exams, exam reports, gastrointestinal perforations, skin lesions, falls and medication errors. The rate of adverse events (harm to patient) in patients undergoing any endoscopic procedure was 0.06%.

Conclusions: The incidence of unnecessary harm (adverse event) associated with any endoscopic procedure was relatively low in this study. However, the identification of reported incidents is crucial for evaluating and improving the quality of care provided to patients.

Keywords: Gastrointestinal endoscopy; Medical errors; Patient safety; Risk management.