Follow-up is one of the greatest factors contributing to patient safety.

Prevention Strategies

Study Analyzes Role of Human Factors in Non-Procedural Patient Safety Incidents

Five categories accounted for over 80 percent of all the so-called non-procedural patient safety incidents, with "follow-up and surveillance" making up the largest component (23.4 percent).

A study out of England and Wales and published in Endoscopy assessed the human factors related to endoscopy that can impact patient safety.

Five categories accounted for more than 80 percent of all of the so-called non-procedural patient safety incidents, with "follow-up and surveillance" making up the largest component (23.4 percent), according to the study.

Endoscopy procedures carry some inherent risk, but there has been little research on the wider safety concerns related to the endoscopy service itself, according to the authors — everything from booking and communication errors before a procedure to follow-up after a procedure.

Reports were pulled from the National Reporting and Learning System (NRLS) and a cross-sectional human factors analysis of data was performed. The researchers identified 487 human factors codes.

Among them, decision-based errors were the most common act prior to the patient safety incident occurring. Other common preconditions leading to an incident were what the study called “environmental factors” — overwhelmed resources, ineffective team communication and patient factors.


Related Content: Does Reprocessing’s Complexity Hinder Disinfection?


Based on the findings, the researchers outlined seven key recommendations for improving safety, including standardizing handoff between core team members and external teams, better written and verbal communication with patients, and improved workforce planning.

"Demand and capacity planning" is an area the researchers highlight to focus improvements on, due to an increasing burden on endoscopy services. 

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