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

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; P = 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.

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