Development of a national root cause analysis system for post-endoscopy upper gastrointestinal cancer

Background and study aims: Post-endoscopy upper gastrointestinal cancer (PEUGIC) is a key performance indicator for endoscopy. PEUGIC represents a delay in diagnosis: a patient has an endoscopy that did not diagnose cancer, and another investigation, usually endoscopy, 3 to 36 months later that diagnoses upper gastrointestinal (UGI) cancer. We describe a national system to identify PEUGIC and undertake root cause analysis. Methods: This retrospective national study was undertaken in the English National Health Service (NHS) and consisted of: 1) identification of PEUGIC; 2) development of an online platform for root cause analysis; and 3) pooled national analysis of PEUGIC. Two national datasets--Hospital Episode Statistics and National Cancer Registration and Analysis Service’s cancer registry--enabled identification of people diagnosed with UGI cancer who had endoscopy in the previous 3 to 36 months without a cancer diagnosis (PEUGIC). The online portal informed every endoscopy provider of their PEUGIC and enabled a comprehensive root cause analysis. Results: This methodology was successful in identifying 3907 PEUGIC from January 1, 2017 to October 30, 2023. Root cause analysis was completed for 2666 PEUGICs during the study period and represents the world’s largest cohort of PEUGIC. 664 (17%) cases were ineligible on local review as they did not meet study PEUGIC criteria. Conclusions: A process to identify PEUGIC across a national healthcare system and to perform root cause analysis was described. The methodology is transferable to other healthcare systems with large national datasets, but even without such datasets, the root cause analysis process developed allows identification of learning from PEUGIC for local endoscopy quality improvement.