The aim of this study was to assess the effect of the introduction of peer review processes on the quality of multiple-choice examinations in the first three years of an Australian medical course. The impact of the peer review process and overall quality assurance (QA) processes were evaluated by comparing the examination data generated in earlier years (2008) with those held under the new QA regime (2009 and 2010) from the same blueprint. Statistical analysis and comparisons of overall examination performance were made by year. Regarding multiple-choice questions (MCQs), item analysis was used to compare the proportion of difficult and discriminating items and functional distractors on summative examinations in 2008 (pre-implementation of peer review) and 2009 and 2010 (post-implementation). The impact of peer review processes resulted in a decrease in the number of items with negative discrimination; increases in reliability, appropriate item difficulty, and numbers of items with significant discrimination. There was an associated improvement in the effectiveness of distractors for the MCQ items. The trend of overall improvement in the quality of MCQ items continued in 2009 and 2010. The introduction of QA processes, specifically peer review of MCQ items has resulted in a sustained improvement in the quality of MCQ items within our examinations. (Contains 3 tables and 1 figure.)