Data Collection - Discrepancies Between Pre-operative and Post-operative diagnoses
The requirement found at PI.01.01.01 EP 4 requires organizations to collect data on "All significant discrepancies between preoperative and post-operative diagnoses, including pathologic diagnoses." Please provide examples of such data.
Any examples are for illustrative purposes only.
Although the accreditation manual does not provide a definition for the term "significant" as it relates to PI.01.01.01 EP 4, providing the following examples may help clarify the expectations of this requirement:
Although the accreditation manual does not provide a definition for the term "significant" as it relates to PI.01.01.01 EP 4, providing the following examples may help clarify the expectations of this requirement:
- Surgery scheduled for a cyst removal and post-operatively was determined to be a malignant tumor
- Exploratory laparotomy performed with a diagnosis of "acute abdomen" - no pathology found, but the patient was then diagnosed with C-Diff,
- A patient scheduled for an appendectomy for "acute appendicitis" and the appendix was normal on pathology exam; etc.
An organization's pathology services, medical staff and organizational leadership would determine additional examples of such discrepancies to track. Consideration should be given to the scope of services provided and patient population served by the organization.
Manual:
Ambulatory
Chapter:
Performance Improvement PI
Last reviewed by Standards Interpretation: February 28, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: February 06, 2017
This Standards FAQ was first published on this date.
This page was last updated on February 28, 2022
with update notes of: Review only, FAQ is current
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