title: Intraoperative pathology consultation: error, cause and impact.
abstract: BACKGROUND
  Correlation of intraoperative frozen section diagnosis with final diagnosis can be an important component of an institution's quality assurance process.
  
  
  METHODS
  We performed a quality assurance review of 1207 frozen section diagnoses from 812 surgical cases performed in the Hamilton Regional Laboratory Medicine Programme during a 6-month period in 2007. We reviewed the frozen section and permanent slides from all potentially discordant cases using a multiheaded microscope to arrive at a consensus pertaining to the type and reason for error. We reviewed the clinical record to determine whether there had been a potential adverse impact on immediate clinical management.
  
  
  RESULTS
  Frozen sections were most commonly requested for head and neck, nervous system and female genital tract specimens. Twenty-eight frozen sections (3%) were deferred. We identified 24 discordant diagnoses involving 3% of cases and 2% of specimens. The organ systems showing the greatest frequency of discordance relative to the total number from that system were the nervous system, head and neck, and the lungs. Of the errors identified, most occurred owing to diagnostic misinterpretation, followed by problems related to tissue sampling. There was a potential adverse impact on immediate clinical management in 14 cases.
  
  
  CONCLUSIONS
  Our results add to the Canadian data on the correlation between frozen sections and permanent sections; we note comparability to the concordance rates reported in the literature.
authors.affiliation: Hamilton Regional Laboratory Medicine Programme, Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ont., Canada. etienne.mahe@medportal.ca
authors.forename: Etienne
authors.initials: E
authors.lastname: Mahe
authors.forename: Shamim
authors.initials: S
authors.lastname: Ara
authors.forename: Mona
authors.initials: M
authors.lastname: Bishara
authors.forename: Annie
authors.initials: A
authors.lastname: Kurian
authors.forename: Syeda
authors.initials: S
authors.lastname: Tauqir
authors.forename: Nafisa
authors.initials: N
authors.lastname: Ursani
authors.forename: Pooja
authors.initials: P
authors.lastname: Vasudev
authors.forename: Tariq
authors.initials: T
authors.lastname: Aziz
authors.forename: Cathy
authors.initials: C
authors.lastname: Ross
authors.forename: Alice
authors.initials: A
authors.lastname: Lytwyn
mesh_terms: D003951:Diagnostic Errors; D005260:Female; D005629:Frozen Sections; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D009864:Ontario; D010340:Pathology, Surgical; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors