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8 %. Adequate PICI was associated with higher ADR (odds ratio 1.16, 95 % confidence interval 1.12 - 1.2. When using a cutoff of 5 mg midazolam, median dose in this Dutch population, adequate PICI was achieved in 95 410 colonoscopies (88.9 %). PICI appeared to be heavily dependent on sedation practice. Because of wide variation in sedation practice between individual endoscopists and countries, the benefit of PICI as a quality indicator is limited. PICI appeared to be heavily dependent on sedation practice. Because of wide variation i