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A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer
Journal article   Peer reviewed

A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer

Umair Kamran, Dominic King, Abdullah Abbasi, Ben Coupland, Nosheen Umar, Warren C Chapman, Srisha Hebbar and Nigel Trudgill
Endoscopy, Vol.55(2), pp.109-118
02/01/2023
DOI: 10.1055/a-1917-0192
PMID: 36044914

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Abstract

BACKGROUND : Missing upper gastrointestinal cancer (UGIC) at endoscopy may prevent curative treatment. We have developed a root cause analysis system for potentially missed UGICs at endoscopy (post-endoscopy UGIC [PEUGIC]) to establish the most plausible explanations. METHODS : The electronic records of patients with UGIC at two National Health Service providers were examined. PEUGICs were defined as UGICs diagnosed 6-36 months after an endoscopy that did not diagnose cancer. An algorithm based on the World Endoscopy Organization post-colonoscopy colorectal cancer algorithm was developed to categorize and identify potentially avoidable PEUGICs. RESULTS : Of 1327 UGICs studied, 89 (6.7 %) were PEUGICs (patient median [IQR] age at endoscopy 73.5 (63.5-81.0); 60.7 % men). Of the PEUGICs, 40 % were diagnosed in patients with Barrett's esophagus. PEUGICs were categorized as: A - lesion detected, adequate assessment and decision-making, but PEUGIC occurred (16.9 %); B - lesion detected, inadequate assessment or decision-making (34.8 %); C - possible missed lesion, endoscopy and decision-making adequate (8.9 %); D - possible missed lesion, endoscopy or decision-making inadequate (33.7 %); E - deviated from management pathway but appropriate (5.6 %); F - deviated inappropriately from management pathway (3.4 %). The majority of PEUGICs (71 %) were potentially avoidable and in 45 % the cancer outcome could have been different if it had been diagnosed on the initial endoscopy. There was a negative correlation between endoscopists' mean annual number of endoscopies and the technically attributable PEUGIC rate (correlation coefficient -0.57;  = 0.004). CONCLUSION : Missed opportunities to avoid PEUGIC were identified in 71 % of cases. Root cause analysis can standardize future investigation of PEUGIC and guide quality improvement efforts.
 Barrett Esophagus - pathology Endoscopy, Gastrointestinal Esophageal Neoplasms - diagnosis Esophageal Neoplasms - etiology Esophageal Neoplasms - pathology Female Gastrointestinal Neoplasms - diagnosis Gastrointestinal Neoplasms - etiology Humans Male Root Cause Analysis State Medicine

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