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

Unlabelled: 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.

Aim: 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.

Methods: 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.

Results: 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.

Conclusion: 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.