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Root Cause Analyses of Reported Adverse Events Occurring During Gastrointestinal Scope and Tube Placement Procedures in the Veterans Health Association

Soncrant, Christina MPH*; Mills, Peter D. PhD, MS*†; Neily, Julia RN, MS, MPH*; Paull, Douglas E. MD; Hemphill, Robin R. MD, MPH

doi: 10.1097/PTS.0000000000000236
Original Article: PDF Only

Objective This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur.

Methods This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database. Adverse event type, procedure, location, severity, and frequency were extracted. Spearman ρ was used to determine associations between types of adverse events and harm levels.

Results We reviewed 27 cases of reported adverse events related to GI invasive procedures. Of the adverse events for which we could determine location (n = 25), 10 (40%) were in the operating room and 15 (60%) occurred in a nonoperating room. Endoscopies were associated with the least amount of harm. The most frequently reported adverse event types were human factors (22.22%, n = 6) and retained items (18.52%, n = 5). Retained item events were associated with the most harm. The most common root causes were lack of standardization in the process of care and suboptimal communication.

Conclusions Retained items after invasive procedures and human factors errors were the most common and harmful type of adverse event in this study. Efforts to reduce adverse events during GI invasive procedures include improving situational awareness of the risk of retained items, standardization of care, communication between providers, and inspection of instruments for intactness before and after procedures.

From the *Veterans Health Administration, National Center for Patient Safety, Field Office, White River Junction, Vermont; †The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and ‡Veterans Health Administration, National Center for Patient Safety, Ann Arbor, Michigan.

Correspondence: Christina Gilbert, MPH, VAMC (11Q), 215 North Main St, White River Junction, VT 05009 (e-mail:

There was no funding received for the development of this article, and there are no other conflicts of interest regarding this submission.

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