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Operating Room & Surgical Case

Review Committee
Dr Khan Zaheed ali khan

Quality Management Director

Committee Charge:
The committee shall oversee the appropriate
utilization of operating rooms coordinate policies
and procedures relating to their function.
Review continually practices in operating rooms
and recovery areas to ensure that such practices
represent the highest standards of quality,
patient safety, and efficiency. Takes actions and
reassess those actions for effectiveness.

Continually review the appropriateness of use of

the operating rooms/recovery room and make
recommendations to promote safety and enhance
efficiency in utilization of operating rooms.
The Operating Room committee approves all of the

To review periodically records of significant surgical

Review major discrepancy in diagnosis and
management, including review of laboratory and
radiological findings and to evaluate surgical team
compliance with standards, policies & procedures.

To monitor all surgical operations & other invasive

procedures against the following criteria:
Adequacy of clinical history taken.
Appropriateness of the procedure selected
Preparation of the patient
The way the procedure is performed & the patient
Post-operative procedure care & complications if any
including ICU admission or readmission to OR.
Review of informed consent
Evaluate blood transfusion and blood losses.

Review unplanned removal, injury or repair of an organ or a structure

during surgery.

To develop standards of care guidelines for various procedure.

Review all pre & post-operative discrepancies of diagnoses either

pathological or clinical; tissues & non-tissues.
Review specific case. e.g. perforated Appendix.

Review all questionable cases against pre-determined criteria.

Screen potential problems & try to identify any particular pattern.

Monitor new procedure introduced to Al Yousif Hospital.

Update the criteria for surgical case review


Refer cases of morbidity & mortality to the

particular clinical services concerned.

Functions as reference to all surgical disciplines.

Review Nosocomial infection with other

concerned committees

Committee has the authority to review medical records and
any other hospital documents that relate to matters under
its jurisdiction.

Committee has the authority to request information from

any individual concerning matters under its jurisdiction.
Committee has the authority to request other to conduct
follow-up activities on matters under its jurisdiction