ABSTRACT
BACKGROUND: Increased demand for endoscopic procedures has led to the provision of these services without prior consultation (open access). The need for accurate medical referral information for these patients is vital for patient safety. OBJECTIVE: To assess the accuracy of endoscopic referral information. DESIGN: Over a 4-month study period, patient referral forms were evaluated to determine the accuracy of medical information on patient referral forms by using direct interview with the patient and/or the caregiver. Inconsistencies were validated against medical records. SETTING: Large academic medical clinic. PATIENTS: A total of 868 open-access patient referrals for upper endoscopy and colonoscopy services. MAIN OUTCOME MEASUREMENTS: Referral information about medical diagnoses, medications, allergies, need for antibiotic administration, and current coagulopathies. RESULTS: Inaccurate medical referral information was provided to the endoscopist in 8.8% of referrals (n = 76). Among referrals containing errors, there were a total of 95 significant medical information errors, which, if left undetected by preprocedure review, could have resulted in serious adverse consequences for patients undergoing endoscopy. LIMITATIONS: Study limited to an academic clinical setting. CONCLUSIONS: Patient referrals for endoscopic services in an open-access referral system contain unacceptably high numbers of errors, which place patients at risk for adverse outcomes from endoscopic procedures.
