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Canadian Journal of Gastroenterology
Volume 26, Issue 2, Pages 71-78
Original Article

Indicators of Safety Compromise in Gastrointestinal Endoscopy

Mark R Borgaonkar,1 Lawrence Hookey,2 Roger Hollingworth,3 Ernst J Kuipers,4 Alan Forster,5 David Armstrong,6 Alan Barkun,7 Ronald Bridges,8 Rose Carter,9 Chris de Gara,10 Catherine Dube,8 Robert Enns,11 Donald MacIntosh,12 Sylviane Forget,7 Grigorios Leontiadis,6 Jonathan Meddings,8 Peter Cotton,13 Roland Valori,14 and on behalf of the Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group

1Department of Medicine, Memorial University of Newfoundland, St John’s, Newfoundland and Labrador, Canada
2Department of Medicine, Queen’s University, Kingston, Canada
3Department of Medicine, The Credit Valley Hospital, Mississauga, Ontario, Canada
4Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
5Department of Medicine, University of Ottawa, Ottawa, Canada
6Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
7Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
8Department of Medicine, University of Calgary, Calgary, Canada
9Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
10Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
11Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
12Division of Gastroenterology, Dalhousie University, Halifax, Nova Scotia, Canada
13Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
14Gloucestershire Royal Hospital, Gloucestershire, UK

Received 2 December 2011; Accepted 5 December 2011

Copyright © 2012 Canadian Association of Gastroenterology. This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (, which permits reuse, distribution, and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes.


The growth in the use of endoscopy to diagnose and treat many gastointestinal disorders, and its central role in cancer screening programs, has led to a significant increase in the number of procedures performed. This growth, however, has also led to many variations in, among others, the provision of services, the choice of sedative medications and the training of providers. The recognition of the significance of quality in endoscopy has prompted several countries, including Canada, to initiate efforts to adopt nationwide quality improvement programs. The Canadian Association of Gastroenterology formed a committee to review endoscopy and quality with the aim of stimulating improvement. This article focuses specifically on patient safety indicators that were developed at a consensus conference aimed at generating a broad range of recommendations for selected endoscopic procedures, which if adopted, could lead to significant changes in how endoscopy services are provided.

INTRODUCTION: The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs.

OBJECTIVE: To identify key indicators of safety compromise in gastrointestinal endoscopy.

METHODS: The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance.

RESULTS: A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related – the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm/bronchospasm; procedure-related early – perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed – death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications.

CONCLUSIONS: The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.