[2120] Review of Tumor Board Cases as Part of a QA Program: Impact on Clinical Care in a Non-Subspecialized Tertiary Hospital: A Review of 2,604 Cases

Mfon Udo, Meenakshi Singh, Jingxuan Liu, Carmen Tornos. SUNY Stony Brook University Medical Center, Stony Brook, NY

Background: Part of our current QA process includes the review of slides of all cases presented at all Hospital tumor boards. The review is done by attendings with interest/expertise in each subspecialty area. Results are tabulated by 2 senior pathologists on a quarterly basis, presented at the QA meetings and kept in computerized format.
Design: We reviewed the results of all QA tumor boards from January 2009 until March 2011. This review covers 10% of the total yearly workload of the department and is designed to address errors in all phases of surgical pathology including change in diagnosis or stage, typographical errors, errors in patient's information, inadequate clinical history or incomplete data in the cancer CAP sign out templates.
Results: 2604 cases from 395 tumor board meetings were reviewed including: Breast 722, gynecology 348, gastrointestinal 309, melanoma 275, leukemia/lymphoma 271, urology-188, thoracic 176, head and neck 154, soft tissue 88, and pediatrics 73. In total, 46 issues (1.76%) were identified including 7 (0.27%) in the pre-analytic phase, 1 (0.034 %) in the analytic phase and 38 (1.46%) in the post-analytic phase. In the pre-analytic phase, there was inadequate clinical history in 4 cases, wrong patient's DOB in 1 case, wrong clinician's name in 1 case, and a grossing error in 1 case (failure to identify two separate tumor nodules in a lung specimen). In the analytic phase there was one false positive margin status due to the presence of therapy artefact. In the post-analytic phase: 16 cases had a change in pathologic staging; 15 cases had typographical errors, and 7 cases had incomplete CAP reporting.
Conclusions: Review of tumor board cases can be used as an internal benchmark to monitor error rate in surgical pathology in the pre, post and analytic phases. In our series, patient care benefited from this review in at least 25 cases (0.9%) in which therapy, and prognosis were affected when pathologic staging was changed, CAP reports added important missing information, and one margin was found to be negative rather than positive.
Category: Quality Assurance

Monday, March 19, 2012 1:00 PM

Poster Session II # 243, Monday Afternoon


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