Conclusions Learning outcomes centre around managing highrisk patients, pre-assessment and endoscopist factors. Developing systems and training are actions in direct response to learning outcomes. Refining data collection methods was identified as a way to improve learning from AEs. There were a variety of methods to disseminate learning and feedback to endoscopists but no discernible mechanisms to share learning between units were identified. There needs to be a more robust way of collecting

more »

... d collating endoscopy AE data, with a focus on shared learning between services.