Gastrointestinal (GI) endoscopy is widely regarded as safe, yet patient safety incidents (PSIs) do occur, with scarce information on contributory factors (CF).¹ This study aims to systematically identify contributory factors (CFs) across the endoscopy pathway using narrative reports from the National Reporting and Learning System (NRLS) in England and Wales, mapped to the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 human factors framework. By capturing latent risks across its various domains, we seek a system-wide understanding of where, in the endoscopy journey, significant patient harm occurs and why. We also seek to translate these insights into team-based simulations, delivered in-situ, designed to reflect real-world risks.

We retrospectively analysed relevant PSI narrative reports submitted to the NRLS between 2017 and 2022, focusing on significant incidents, resulting in moderate or severe harm or death. Incidents were characterised by procedure type, urgency, and stage of patient care. Using a mixed inductive and deductive approach we identified CFs, based on the SEIPS 2.0 domains using established content analysis principles.² High-yield in situ simulation scenarios were developed by translating key descriptors and CFs into realistic, contextually grounded scenarios. These scenarios reflected system vulnerabilities and provided a foundation for exploring team communication and adaptive decision-making in complex, real-world settings.

Analysis of 1,442 PSI reports revealed that incidents most commonly occurred during oesophago-gastro-duodenoscopies (31.2%), colonoscopies (29.4%), and Endoscopic Retrograde Cholangio-Pancreatography (16.4%). Elective procedures accounted for 44.8%, with emergencies comprising 17.0%. PSIs were most frequently reported peri-endoscopically (44.5%), followed by pre- (28.3%) and post-endoscopy (27.3%) phases.

Content analysis of 1,057 reports identified 1,484 CFs. The Person domain predominated (52.0%), with communication failures (50.6%) and gaps in knowledge, competence, or skills (33.7%) most commonly reported. Organisational factors (18.7%) reflected resource availability, staffing, and workflow challenges, while Task factors (17.5%) related to procedural complexity and patient-specific considerations. Tools and Technology (7.3%) and External factors (3.7%, mainly COVID-19–related) were less frequently reported CFs

These findings were translated to create team-based in-situ simulation scenarios addressing real-world vulnerabilities (such as management of complex patients with comorbidities and anticoagulation, navigating incomplete or conflicting documentation, responding to peri-procedural complications such as perforation, withdrawal of consent). Each scenario was explicitly mapped to CFs identified from the analysis and are currently being used as a basis to study endoscopy team communication and adaptive capacity in participating centres.

This content analysis of at least moderate harm incident reports in GI endoscopy highlights that PSIs arise from complex interactions across the entire work system, with Person and Organization domains most frequently reported. Communication failures accounted for over half of person-related CFs, often occurring across teams, with patients, or via incomplete documentation. This highlights a mismatch between current endeavours to improve safety in endoscopy care—typically focused on improving individual technical performance—and where harm actually originates. Latent system vulnerabilities amplify seemingly minor errors into significant adverse events, including delayed diagnosis, missed pathology, or lost surveillance.

Addressing these risks requires a reconceptualization of safety that extends beyond the procedure room to encompass the entire multidisciplinary team. To address some of those challenges, we have developed and delivered multi-centre, in-situ team-based simulations based on those real-life risks. These simulations are now being used to study team communication and adaptive capacity, offering an evidence-informed, proactive approach to improving patient safety and fostering resilient endoscopy systems.