Failure to write a comprehensive endoscopy report that addresses the clinical question
Despite variations in endoscopy reporting software, most generally utilise mandatory automated fields with accompanying free text options. Report writing is an essential aspect of the procedure completed at the end of the case. Multiple potential distractors relate to transferring the patient from the procedure room and getting the next patient in. This is often compounded by the endoscopist tending to many tasks simultaneously (dual-task interference) and endoscopist fatigue after a demanding case. It is clear to see how errors can creep in. High-quality data entry into the endoscopy report enables us to accurately measure patient outcomes, supporting safety and quality measures.24 Critical aspects of endoscopy reporting are summarised in the information box below (figure 4).
Figure 4 | Critical aspects of endoscopy reporting.
Separately, the endoscopy report is a crucial medical document and a surrogate marker of the quality of the procedure. Established guidance exists on what constitutes an effective endoscopy report, and high-quality photo-documentation of important landmarks and pathology is essential.15, 25 This is particularly important when examining aspects of colonoscopy quality, such as PCCRC. It is important to identify if a lesion was ‘missed’ at colonoscopy or if accelerated cancer pathways might account for interval cancers.
The endoscopy report should accurately reflect the case, including patient tolerance, sedation strategy, colonoscope subtype and adjuncts, and any technical difficulties encountered and how they were overcome - all of which may inform any subsequent colonoscopy. The target audience should be considered, and communication should be adapted as the patient, the primary care doctor, and the referring clinician will receive the report.
The endoscopist should ensure that the endoscopy report addresses the clinical question for that patient and is not solely a technical report. To this end, a clinical diagnosis, histology results, management of anticoagulant agents, an indication of next steps and clarity around any subsequent surveillance procedures should be included where feasible.
Most importantly, the report should read as a stand-alone document where the clinical indications, relevant comorbidity, endoscopic diagnoses, and subsequent management is transparent such that should the patient present at another unit with a post-procedural complication, all the information is readily available from the endoscopy report. It should also be remembered that the report may have to be referred to in medico-legal cases. Care and attention should be given to ensure the report reflects the clinical episode, all the findings, and limitations.
In summary, colonoscopy is a complex procedure, and errors in endoscopy will occur. A focused consideration of technical and non-technical skills can reduce the incidence of avoidable mistakes and positively impact colonoscopy patient safety and quality.
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