PTU-114 Learning from adverse events: A study of JAG endoscopy units

Introduction To meet JAG accreditation standards, endoscopy services are expected to have processes to identify, respond to and learn from adverse events (AEs). Units provide evidence to demonstrate they have met the set standard through audits of mortality and readmission after endoscopy. We conducted the first analysis of UK-wide learning outcomes from AEs based on mortality and readmission data. The aims were to understand how evidence is collected, describe relevant learning outcomes and resultant actions and processes used to share learning. Methods A retrospective analysis of JAG 30-day mortality and 8-day readmission evidence from 2013–2018 was undertaken, assessing methods of data collection and documentation of learning outcomes. Data from evidence files were extracted and thematically analysed to identify and categorise learning outcomes and action points. This study was approved by the JAG research committee. Results Complete data was available for 59 units. 42 units (71%) used the JAG audit proforma in providing evidence. Where no JAG proforma was utilised, data was sourced from other audit summaries (14%), PowerPoint slides (8%) or other tabulated data (7%). 35 units (59%) documented learning outcomes following readmission or mortality, with 85% stating that outcomes were discussed in a formalised meeting. Learning outcomes and action points are summarised below: Conclusions Learning outcomes centre around managing high-risk patients, pre-assessment and endoscopist factors. Developing systems and training are actions in direct response to learning outcomes. Refining data collection methods was identified as a way to improve learning from AEs. There were a variety of methods to disseminate learning and feedback to endoscopists but no discernible mechanisms to share learning between units were identified. There needs to be a more robust way of collecting and collating endoscopy AE data, with a focus on shared learning between services.