The causes, and impact, of colonoscopic perforation for endoscopists: lessons from a qualitative interview study

Safety and the avoidance of adverse events are crucial in patient care. A number of explanatory variables for the serious adverse event of colonoscopic perforation have been identified; however, the context in which perforation occurs has largely been overlooked, as too has the subsequent impact on the colonoscopist. This study examined the human and environmental factors associated with colonoscopic perforations, along with colonoscopists' reactions to these, with a view to informing strategies for safer practice and clinician support.

This qualitative study explored the experiences of colonoscopists who reported a previous colonoscopic perforation. Semi-structured interviews were undertaken with 11 colonoscopists, recruited through professional networks. Interviews were recorded and transcribed and analysed using a framework approach.

Human and environmental factors contributing to perforation included colonoscopist fatigue, time pressure and equipment failure. Four distinct stages were identified in colonoscopists' reactions to perforation: ' The Perforation Realisation ' comprising a range of strong and powerful emotions; ' The Consequences ' involving feelings of personal responsibility, self-blame, fear of repercussion and vulnerability; ' Acceptance and Refocus ' comprising a period of coming to terms with the perforation; and finally ' Reflection and Learning ' where the colonoscopist reflected on the case and applied learning to their future practice.

This study examines colonoscopists' personal experiences of perforations. It identifies the stages that colonoscopists experience after causing a perforation, and some of the broader contextual factors that can lead to these potentially preventable adverse events. The data suggest the need for greater emotional and pastoral support for endoscopists when such events occur.