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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: 
  •    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.
Last updated on August 17, 2020
Manual: Critical Access Hospital
Chapter: Performance Improvement PI

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