Lessons learned: Preventable misses and near-misses of endoscopic procedures

Endoscopy is a complex procedure that requires advanced training and a highly skilled practitioner. The advances in the field of endoscopy have made it an invaluable diagnostic tool, but the procedure remains provider dependent. The quality of endoscopy may vary from provider to provider and, as a result, is not perfect. Consequently, 11.3% of upper gastrointestinal neoplasms are missed on the initial upper endoscopy and 2.1%-5.9% of colorectal polyps or cancers are missed on colonoscopy. Pathology is overlooked if endoscopic exam is not done carefully, bypassing proper visualization of the scope's entry and exit points or, if exam is not taken to completion, not visualizing the most distal bowel segments. We hope to shed light on this issue, establish areas of weakness, and propose possible solutions and preventative measures.