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Introduction Endoscopy safety focuses on reducing procedural complications, yet significant harm can originate across the patient journey. How teams adaptively maintain safety amid systemic pressures remains unexplored. We analysed endoscopy incident data across England and Wales to characterise contributors to significant harm in patient’s endoscopy journey and used in-situ multi-professional simulations for endoscopy teams informed by these findings to explore team communicative practices sustaining safety.Methods We evaluated 1,442 significant harm endoscopy patient safety incidents (PSIs) reported to NHS England (2017–2022) using content analysis grounded in the SEIPS 2.0 human factors framework to identify contributory factors (CFs). Findings informed the design and delivery of ten video-recorded interprofessional, in-situ simulations across two endoscopy units, involving thirty clinical and administrative participants followed by debriefs, and interviews totalling twenty hours of interactional data, analysed using Conversation and Thematic Analysis.Results PSIs included those leading to moderate (74.5%), severe harm (18.6%), and death (6.9%). Three most common incident types were: known complications (n=587, 40.7%), Follow-up failures (n=270, 18.7%) and timing-related incidents (n=124, 8.6%). Pre (n=408) and post-endoscopy (n=392) phases accounted for 55.5% of incidents.We identified 1,441 CFs (figure 1). Person-related CFs were most common (n=750 52.0%), primarily miscommunication (50.9% of person CFs). Organisational CFs (n=269 18.6%) reflected resource constraints (59.5%); task factors (n=252 17.3%) involved particularly complex cases (52.4%).Analysis of simulations revealed four communication strategies enabling adaptive safe care: Dynamic Observations, Instructions, Action Announcements, and Joint Activity Initiators. Together, they constitute an integrated communicative resource maintaining collective situational awareness, coordinating activities, and planning for uncertainty. Debrief and interviews reveal the role which monitoring and anticipation have in shaping adaptive mechanisms, as well as the subtle work teams perform to bridge the gap between protocolised care and team adaptations.Conclusion Most reported significant harm in endoscopy care occurs outside procedures through miscommunication across the care pathway. Incident-informed simulations revealed four protective team practices: Dynamic Observations, Instructions, Action Announcements, and Joint Activity Initiators. Findings fundamentally reframe endoscopy safety endeavours from solely improving individual technical performance towards understanding how interprofessional teams collectively sustain safe care amid organisational constraints.Abstract P443 Figure 1CF analysis mapped to SEIPS 2.0 domains