Risk Management Strategies and QA

Question 1

Name some pre-autopsy safety and risk issues

Answer 1

Documentation of receipt of body (notification of death)
Warrant of PME
Restrictions
Verification of ID
Communication with support staff (infectious case)

Question 2

Name some autopsy safety and risk issues

Answer 2

Verification of ID (body bag, name tag, warrant PME)
Documentation of clothing and valuables
Organ retention considerations
Documentation of infectious risk incidents
Documentation of personal injury sustained
Completion of incident form
Adherence to needle stik injury protocol

Question 3

Name some post-autopsy safety and risk issues

Answer 3

Organ retention
Authorization to retain organ
COmmunication of need for organ retention
Preparation of form
Completion of form by next of kin
Notification of delayed release of body
Notification of authorization of body release
Updating name tag for UI decendents
Release of body and valuable with appropriate paperwork

Question 4

Name 4 examples of adverse events in autopsy

Answer 4

PME wrong body
Inability to account for decedent’s valuables
Mislabelling of specimens
Release of wrong body to funeral home
Premature release of body without repatriation of rapidly consulted organs
Inability to locate retained organ/stock pot
Release of wrong organ

Question 5

What is quality assurance?

Answer 5

Program for systematic monitoring and evaluation of a project, service or facility to ensure that standards of quality are met.

Question 6

Name examples of QA measures in FP

Answer 6

SOP and minimum standards of practice (guidelines)
Utilization of pathologist who are registered in Registry
Caseload management (limit number of cases)
Audits of practice (peer-review of PM reports and transcripts of experte witness testimony)
Defence/Second opinion
Formal expert witness training
Audits of practice

Question 7

Name 4 main components of QA in OFPS

Answer 7

Register of pathologists

Autopsy performance standards and reporting (guidelines, autopsu report template, peer-review)

Audit of courtroom testimony

Identification of critical incidents and significant quality issues

Question 8

Expected outcome of submission compliance

Answer 8

100%

Question 9

Expected outcome of completeness of the reports

Answer 9

100%

Question 10

Expected outcome of consistency of the repots?

Answer 10

100%

Question 11

Expected outcome of turn around time

Answer 11

90% within 120 days

Question 12

Expected outcome of reports with significant quality issues

Answer 12

0%

Question 13

Expected outcome of number of critical incidents

Answer 13

0%

Question 14

Name some systemic risk factors for adverse outcomes?

Answer 14

No regulatory structure and oversight of practice
No peer-review of reports
No peer-review of EW testimony
No audits of practice
Single-handed practitioners
High caseload: FP ratio
No continuing professional development activity
No academic component to practice
No access to peer-reviewed journals

Question 15

Name some individualistic risk factors for adverse outcomes?

Answer 15

No accredited training, examination and certification in FP
No insight into limitations of knowledge, expertise and experience
Unwillingness to consider the views of other experts
No formal expert witness training and assessment of performance
No audits of transcripts of testimony
No ongoing