Errors in colonoscopy and how to avoid them

Colonoscopy is complex, and endoscopy errors can occur. Targeted consideration of technical and non-technical skills can reduce avoidable errors and increase patient safety.

Translated from the original Italian version.

6 common mistakes in colonoscopy that can be avoided

Performing a colonoscopy requires manual and visuospatial skills, identification of any pathology found, communication with the patient and a wide range of advanced therapeutic knowledge. Furthermore, each colonoscopy differs in factors related to the patient, sedation strategy, anatomical configuration and the skill of the endoscopist. Endoscopists must therefore possess a wide range of skills, working effectively in a team to manage the patient safely. It is therefore not surprising that mistakes can occur.

This article focuses on six common errors in colonoscopy that can be avoided to improve the procedure's safety and perform a high-quality examination. This, in turn, can reduce post colonoscopy colorectal cancer rates (PCCRC), improve patient experience, and their adherence to colonoscopy-based surveillance programmes.

Error 1: Performing a colonoscopy in a patient who does not need it

Colonoscopy is an essential aspect of the investigation of colorectal disease. The judicious and selective use of colonoscopy, for the right patient at the right time in the investigation pathway, is critical. Multiple specialities in primary and secondary care settings may refer patients for colonoscopy. Considering the indication and referral information provided is crucial in determining whether colonoscopy will indeed help answer the clinical question. If not, appropriate alternative investigations may be considered.

A robust pre-assessment process with experienced and knowledgeable nurses is invaluable in determining a patient's suitability for colonoscopy, where factors such as comorbidities, exercise tolerance, sedation issues and ability to comply with bowel preparation can be discussed in detail.

Apart from the invasive nature of the procedure and protecting patients from the experience of an unnecessary colonoscopy, any complication (however 'minor') resulting from a procedure that is not fully indicated, is more difficult to defend. Moreover, selectivity is crucial in the post-COVID-19 era, when one has to manage the vast backlog of endoscopies with limited endoscopic resources.

Error 2: Not being present and involved in the team briefing and checklist

Planning and preparation are fundamental non-technical endoscopic skills. The importance of team briefings and pre-procedural checklists in surgery and endoscopy is increasingly evident.

The team briefing is a crucial opportunity to identify with the endoscopic team the relevant details of the cases on the list and proactively address any issues that may affect the smooth running of the list, and the safety and quality of the colonoscopy. The briefing process allows the endoscopist to be receptive to new, critical, or evolving information, to establish a 'plan B', and to flatten the team hierarchy by improving communication.

The pre-procedure checklist, particularly with the patient present, provides a final opportunity to reconfirm patient consent and manage patient expectations prior to the start of surgery. To close the circle, a team debriefing at the end of a list, or even of a complex case, will allow any problems to be corrected before continuing with subsequent cases.

Error 3: Haste and excessive use of force during ascent

The ascent phase of colonoscopy is essential to establish the progress of the procedure both from the patient's point of view (especially if not sedated) and for any subsequent treatment. It is here that the patient's anxiety and the opportunity to build trust and cooperation can be at their highest.

Intubation allows the endoscopist to determine the phenotype of the colon (atonic and tortuous, or angled and narrow), the adequacy of the bowel preparation, the patient's tolerance, and to make any necessary adjustments. The endoscopist can proactively abandon the procedure and reorganise it with additional bowel preparation, an alternative sedation strategy or an alternative examination such as Computed Tomography Colonography (CTC) or Double Balloon Endoscopy (DBE) to safeguard patient safety. Rectal retroversion can be performed either at the beginning or at the end of the procedure. The main advantage of completing the rectal retroversion at the time of insertion is the immediate identification of significant pathology.

Optimising the endoscopic technique of colon ascent is a crucial skill to train. An efficient ascent allows the endoscopist to spend proportionally more time evaluating the colonic mucosa during the retraction phase and to direct possible therapy.

Error 4: Decline in attention after reaching the caecum

Reaching the caecum is an obvious goal and a key performance indicator (KPI) for colonoscopy. Measuring caecal intubation rates has increased quality and is associated with a reduction in incomplete colonoscopy rates. However, the crux of the procedure begins at this point. It is worth noting that this can coincide with endoscopist fatigue.

Adenoma detection rates are another critical KPI that depends on the retraction technique. It is essential to use the wide range of aids to optimise retraction.

There is also growing evidence that Artificial Intelligence (AI) can aid in the detection and recognition of lesions, and may become an essential adjunct in the coming years. There is a growing literature on the accuracy of AI for both the detection and characterisation of lesions, which could counter problems such as endoscopist fatigue.

Retracting the colonoscope requires time and concentration, hence the recommendation of a minimum retraction time of 6 minutes.

Error 5: Failure to communicate pathological findings and complications

Communication failures are a key component of medico-legal complaints, highlighting the importance of a robust consent process. Communication with the patient and the endoscopic team, even in a 'routine' procedure, is a crucial non-technical endoscopic skill that can be trained and assessed. The focus of endoscopists in training is often on technical skill, but non-technical skills are often what experienced endoscopists put into practice. These include effective communication, teamwork, situational awareness, judgement and decision-making.

It is well known that the management of an accident or safety complication involves a high level of stress, which can negatively affect patient management.

Error 6: Failure to write a complete endoscopic report addressing the clinical issue

The writing of a report is an essential aspect of the procedure. Many potential distractions can occur in the period between the patient transfer from the procedure room and the arrival of the next patient. This is often compounded by the fact that the endoscopist deals with many tasks at once and fatigue after a demanding case. It is clear how errors can creep in. The inclusion of high-quality data in the endoscopic report allows us to accurately measure patient outcomes, supporting safety and quality measures.

The endoscopic report is a fundamental medical document and surrogate indicator of procedure quality. There are established guidelines on what constitutes an effective endoscopy report. The endoscopy report should accurately reflect the case, including patient tolerance, sedation strategy, type of colonoscope and ancillary instruments used, as well as any technical difficulties encountered and how they were overcome, all of which may be useful for any subsequent colonoscopy.

The endoscopist must ensure that the endoscopy report answers the clinical question of that patient and is not just a technical report. To this end, a clinical diagnosis, histological findings, management of anticoagulant agents, an indication of next steps and clarity on any subsequent surveillance procedures, where possible, should be included.

Above all, the report must be read as a stand-alone document in which clinical indications, relevant comorbidities, endoscopic diagnoses and subsequent management are transparent, so that if the patient presents to another unit with a post-procedure complication, all information is readily available from the endoscopic report.

  1. Matharoo M, Ravindran S and Thomas-Gibson S. Mistakes in colonoscopy and how to avoid them. UEG Education 2023; 23: 4-7