a. All microscopic tissue examinations of surgical tissue are performed by a staff pathologist and all surgical tissue diagnoses are made by a staff pathologist.
b. Each day, all pathologists participate in our QA conference at the multi-headed microscope and review 100% of the biopsy and rush cases received. This includes review of frozen section diagnoses where there are any discrepancies between intraoperative diagnosis and final diagnosis. An attendance record is kept. Unresolved differences of opinion are recorded and can be sent to an outside consultant for review (usually the AFIP or NIH).
c. Every surgical pathology and cytology report is reviewed for any errors (in identification or completeness) and delinquencies. This review occurs at the time of report release (to the VISTA Computer System) by the pathologist who signs the case, and by the Chief, surgical pathology, who issues a lateness monitor.
a. Notification of a new positive (for cancer) diagnosis, with the exception of basal cell carcinoma of skin.
b. Notification of unsatisfactory specimens (new for 1998 CAP inspection).
P-0650 .......... CONSULTATION, NOS P-0658 .......... CONSULTATION, BY EMAIL P-0659 .......... CONSULTATION, BY TELEPHONE P-30121 .......... TUMOR BOARD PRESENTATION
a. The final report must specify the disparity.
b. The clinician submitting the specimen must be notified of the disparity.
c. The final report must document that the clinician was notified of the disparity.
d. The disparity must be discussed at the daily QA conference.
e. The disparity must be documented in the monthly pathology monitor submitted to the Chief, Pathology and Laboratory Medicine.
a. The consultation is delivered to the Chief, Surgical Pathology Section.
b. One copy of the consultation is added to a loose-leaf-bound collection of consultations kept in the department.
c. One copy is attached to the copy of the report that is kept in the Department.
d. The findings of the consultation are summarized by the staff pathologist for the case, as a supplemental report.
e. If the results of the consultation are of consequence to the clinicians caring for the patient or if the clinician is waiting for the results of the report for any reason, the clinician is notified of the result of the consultation and the notification is documented as a supplemental report.
f. If there is a discrepancy between the consultant diagnosis and the diagnosis rendered in our department, the case is reviewed at surgical pathology QA conference, and a supplemental report is written according to the consensus reached by all the pathologists.
g. Consultation cases are all SNOMED-coded (the consultation code is 3005) and can be retrieved at any time via SNOMED-search.