[Two years of mortality and morbidity conferences in a hospital gastrointestinal endoscopy unit]

Mortality and morbidity conferences (M & MC) are designed to establish a collegial analysis of all complications in order to define their cause, assess avoidability and propose corrective measures aimed at preventing recurrence of the same kind of complications.

The aim of this study was to report the results of a quality improvement program focused on the complications of gastrointestinal endoscopy in a hospital endoscopy unit.

From 1/7/1999 to 30/6/2001, the complications of gastrointestinal endoscopic procedures were systematically and prospectively recorded and then retrospectively analysed during monthly M & MC.

Eleven thousand seven hundred forty-four procedures were performed and 79 complications (0.7%) were recorded and analyzed. Seventy percent of the complications occurred during therapeutic procedures. Thirty-four percent of complications were due to an error: 22 attributed to the endoscopists, 4 to the nurses and 1 to the material. Thirteen percent of the complications were considered avoidable and 24% probably avoidable. The rate of avoidable complications was 0.07% for diagnostic procedures and 1.4% for therapeutic procedures (P<0.001). Avoidable complications affected mainly endoscopic gastrostomy procedures (48%) and ERCP (24%). The analysis of 15 complications enabled seven corrective measures which concerned 52% of avoidable complications.

Systematic prospective recording of complications and careful exhaustive retrospective analysis during M & MC are efficient and complementary tools for continuous quality improvement programs in gastrointestinal endoscopy.