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 decisionmaking, 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.