84-09 Surgical case review

Surgical case review shall be performed as part of the hospital's peer review and quality improvement activity on an ongoing basis, at least monthly, by each department/division (as appropriate) regularly doing surgical procedures. The review shall include indications for surgery and all cases in which there is a major discrepancy between preoperative and postoperative (including pathologic) diagnoses. Discrepancies between the clinical impression and tissue removed during a surgical procedure are identified by pathology and then referred to the appropriate department performing surgical procedures for review. A screening mechanism based on predetermined criteria may be established for cases involving no specimens. Written records of the evaluations and any action taken shall be maintained in the quality and operations improvement division, available to the medical director or the director's designee and the clinical department chairperson or their designee.

(Board approval dates: 9/6/2002, 4/6/2016)