Quality Assurance

Surgical Review:

Wednesday at 10:00 a.m. in the Division Library (RoomA552 PUH); attended by all Division clinical faculty and fellows

Evaluation of all Intraoperative Consults

Discrepancies between frozen and final diagnosis are reviewed and evaluated based on the following criteria:

1. Failure to identify the lesion grossly
2. Inappropriate selection of material for evaluation
3. Sectioning problem
4. Staining problem
5. Interpretation problem
6. Failure to communicate with surgeon
7. Labeling problem

Evaluation of all diagnostic biopsy permanent sections:

Disagreement categories

Minor - Disagreement with no effect on patient care
Some - but not significant consequences for patient care
Major - serious impact on patient care

Autopsy Review:

10% of autopsies will be peer reviewed using the following criteria:

1. Are all significant NP diagnosis made correct?
2. Do the neuropathologic findings correlate with clinical findings?
3. Do the gross and microscopic descriptions support the final NP diagnosis and the causes of the neurologic disease?
4. Is the spelling, grammar and syntax of the NP report correct?
5. Is the NP portion of the report signed within 40 days of the autopsy?