Performance measure	We recommend endoscopy services perform a root cause analysis of major events, such as missed cancers, unplanned admissions, and unexpected deaths following endoscopic procedures, and use the learning from the analysis to improve the service
Domain	Safety
Category	Process
Rationale	As adverse events are so rare in endoscopy, it is reasonable to review them to determine whether anything could have been done, with the benefit of hindsight, to prevent them, this being a basic safety behaviour: learn from things that happen to avoid them recurring Root cause analysis is a specific process whereby every aspect of the event is reviewed to extract maximum learning There is a question of what ‘major’ means in this context, with various publications having categorized degrees of harm, but no equivalent publications on quality; in addition, there are some indicators that are not clearly quality or safety issues: for example, endoscopists would regard delayed diagnosis of cancer as a major quality indicator but for the patient it is a major adverse event and, because of this importance to the patient, it has been included here as a safety measure Services might consider using a critical incident reporting system (CIRS); a process of learning from adverse events such as this is how the airline industry reduces the risk of planes crashing
Standards	Minimum standard: a list of known major adverse events relevant to the service, with a reporting and review process that systematically identifies these major adverse events and learns from them Target standard: actions required in response to learning from major events are implemented within 3 months of being reported
Consensus agreement	88.89% (3 undecided)
PICO	Not applicable
Concordance with other guidelines	ASGE Yes	Canada Yes	EU Not assessed	GRS/JAG accreditation Yes
Evidence grading	Low/very low