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Celebrating World Patient Safety Day from the JAG perspective
17 September 2020

 The challenges faced by health workers has been in the spotlight in recent months, with due recognition of the stressful environments they often work in. Much evidence exists highlighting that this can lead to errors in delivery of patient care. It’s therefore not surprising that this year’s World Patient Safety Day focuses on health worker safety as a priority for patient safety. The World Health Organisation set up the initiative to increase awareness, engagement and understanding of patient safety globally and these core principles run throughout the work that JAG does. 


Here’s a roundup of our patient safety work over the last few years.


JAG safety strategy

Our safety strategy was developed over 2 years ago to address areas in endoscopy that required further understanding and insight. The strategy was formed by a multi-professional working group and focused on the following areas:

This initiative is designed to complement other safety domains, primarily within that the Global Rating Scale (GRS) and accreditation standards. A great deal of the JAG safety strategy also reflects the principles of the 2019 NHS patient safety strategy: insight, involvement and improvement. 


Understanding safety in endoscopy

A central tenet of both the JAG and NHS  strategies is increasing our understanding of safety. Last year, we conducted our first ever safety census, which investigated key areas of interest identified by the JAG safety strategy. The survey highlighted regional variation in GI bleeding, preassessment and sedation practice. Additionally, provision for upskilling, supporting underperformance and training in human factors was varied.  


We are currently collaborating with the National Reporting and Learning System (NRLS) to gain further insights into safety from a national perspective through analysis of incident reports. Other current research aligned to this project includes:

Investigating the utility of the patient voice to detect safety incidents
Understanding and measuring safety culture in endoscopy 
Have a look at the findings of our census. Have you found similar things in your own service? Are you already looking at other measures of safety, for example, through patient feedback? 


Acknowledging the importance of human factors

Over the past few years, the importance of human factors and their influence on organisations and safety has been recognised in the medical sphere. Recently, the Chartered Institute of Ergonomics & Human Factors (CIEHF) produced a white paper to guide organisations in understanding safety from a human factors perspective. 


Human factors training is an essential part of the JAG safety strategy. The safety census highlighted the variability in provision for human factors and simulation training nationwide. We know that specific human factors training strategies have been shown to be effective and indirectly lead to improved patient safety.


We have been working with our partners at Health Education England to deliver e-learning modules – one of the most recent modules ‘Endoscopic Non-Technical Skills’ highlights the importance human factors in everyday practice. These modules are designed for all endoscopy team members and provide learning through video-based case vignettes. 


The e-learning modules are free to access for healthcare staff and provide essential material for training portfolios, revalidation and general learning. You can access them here.


Impact of COVID-19 on patient safety

The relevance of human factors in everyday practice has been heightened by COVID-19. The onset of the pandemic has seen the way we undertake endoscopy change dramatically. As part of this, our endoscopy teams have had to adapt to novel situations and demands that they have not faced before. In collaboration with other groups, we developed a toolkit for endoscopy teams based on identified human factors challenges that have arisen as a result of the pandemic. This toolkit identifies key points of interaction between endoscopy team members during the course of a normal day. Four cognitive aids support the following: 

1. A whole team huddle – a huddle of all team members in the morning
2. A team briefing prior to each list
3. A debrief following a list 
4. Supporting ENTS whilst donned in PPE.

The endoscopy team toolkit is of direct relevance to World Patient Safety Day 2020, which this year focuses on health worker safety.


You can access the toolkit in full here. How has your service been affected by COVID-19? Do you think the toolkit would be of use to your endoscopy teams? The aids can be altered and adjusted for individual services so have a look and see what works for you.


Shared learning to increase patient safety awareness 

We also publish the ‘Case of the month’ (COTM) series on our website. This series consists of case studies that highlight important learning from patient safety incidents. These can be shared with all endoscopy team members and provide a rich source of learning. Some services have discussed cases during staff breaks, endoscopy user group meetings and monthly education meetings You can print, discuss, learn and share our ISREE COTM series here.

We know there is more to do, and we’ll continue to champion patient safety and the wellbeing of the endoscopy workforce in all our work. You can read more about World Patient Safety Day 2020 here.


Want to get involved?

How has your service supported staff safety during the pandemic?  Join the conversation and speak up for health worker safety today. Tag us on Twitter using the hashtag #WorldPatientSafetyDay to share your experiences with us. 

We are also looking for contributors for our COTM series. If you would like to send in a case study highlighting patient safety incidentsanonymously please contact us at 





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