this may cause reluctance to use these life‐saving medications.
Table 3.3 Intraprocedure quality indicators.
| Patient monitoring | Vital signs (BP, pulse, oxygenation) recorded at least Q5 minutes |
| Medications | Dose, route, and timing of all medications used is recorded |
| Photodocumentation | Major landmarks and findings are photodocumented |
| Sedation reversal | Need to reverse sedation with naloxone, romazicon, or cessation of propofol due to oversedation is recorded |
As previously stated, specific endoscopic procedures have specific quality indicators associated with their technical aspects.
Training in endoscopy should also include a thorough familiarity with these indicators.
Postprocedure
This period extends from scope removal through patient discharge, referring provider communication and pathology follow‐up (Table 3.4). Each endoscopy unit should have an established policy regarding the criteria required before unit discharge. Detailed instructions should be provided to the patient, which address diet, activity, and medication restrictions. Patients should be provided a means of contacting the provider should questions or concerns arise. Finally, feedback to the patient regarding findings and therapies performed should be undertaken [1].
Documentation of procedure
Individual style practices aside, important documentation of the following should be included within each procedure report:
Time, date of procedure
Patient name and identifier
Endoscopists and assistants
Indication and informed consent
Type of instrument
Medication used including dosages
Anatomic extent of procedure
Findings
Limitations or complications of procedure and interventions
Tissue acquisition, use of instruments
Diagnostic impression
Results of therapeutic intervention
Disposition
Recommendations for subsequent care and follow‐up.
Feedback to referring provider
It is the responsibility of the endoscopist to inform the referring provider of the results of the procedure. If pathology is sent or further imaging is ordered, a clear plan outlining responsibility to follow these results must be provided in correspondence to the patient and referring provider.
Table 3.4 Postprocedure quality indicators.
| Discharge criteria | Documentation that the patient has achieved predetermined criteria prior to discharge |
| Patient instructions | Written instructions including resumption of diet, activities (driving), and medications (including anticoagulation) |
| Pathology follow‐up | The plan for follow‐up of any pathology results is specified |
| Procedure report | A complete procedure report is prepared (see text for required elements) |
| Complications | The unit has a policy for monitoring complications |
| Patient satisfaction | Patients are periodically surveyed as to their level of satisfaction with their endoscopic experience |
| Communication | Documentation of communication with referring provider(s) |
Recognition of complications
Complications may be recognized immediately during the procedure or after the procedure has been completed. Some complications may be delayed in onset by several hours (e.g., post‐ERCP pancreatitis) or may not occur until weeks later (e.g., post‐polypectomy hemorrhage). It is the responsibility of the endoscopist and endoscopy unit to identify complications and institute proper therapy in a timely manner. Complications should be recorded and each unit should have a procedure for doing so. For some procedures, the expected frequency of complications is high enough that this may be used as a quality endpoint in and of itself (e.g., post‐ERCP pancreatitis). However, most procedures' complications are rare and therefore their occurrence, or lack of occurrence, is an unreliable marker of an individual's competency. Instead, complications should be used as a tool toward quality improvement. Complications should be regularly reviewed, such as quarterly, in a nonconfrontational forum that focuses on the educational aspects with the goal of improving the quality of care. It should be noted that quality improvement meetings, such as morbidity and mortality conferences, are protected from legal discovery should a lawsuit arise.
Patient satisfaction
All endoscopy units should periodically consider surveying their patients for feedback regarding preprocedure (prep instructions, day of instructions), intraprocedure (endoscopy unit), and postprocedure (follow‐up calls and reporting) experiences. The benefit of this interval review is that it provides information specific to the individual practice as seen from their client base. In these modern times, patient reviews on the Internet are a common practice and capturing this feedback for internal improvement may be helpful in improving the quality of care as seen from the patient's perspective.
Medicolegal issues
Gastroenterologists have an ethical and legal obligation to provide the highest quality of care to their patients. Use of quality markers during the pre‐, intra‐, and post‐procedural period are important to optimizing patient outcome, minimizing patient dissatisfaction, and may be useful for avoiding malpractice litigation. There are limited data on malpractice trends in gastroenterology. In a 2018 JAMA study, gastroenterology ranked 18th among paid malpractice claims [16]. One physician insurance carrier, the Physician Insurers Association of America (PIAA), showed that gastroenterology ranked 21st among 28 medical subspecialties in terms of frequency sued and accounted for 2% of claims. Interestingly, in the majority of the suits (60%), the basis of claims involved cognitive decision‐making rather than therapeutic misadventures [17, 18]. In a separate ASGE survey, 42% of gastroenterologists that had been sued reported that informed consent was an issue [19]. Thus, medical malpractice actions can be brought on because of failure to
