title: How well do we communicate?: a comparison of intraoperative diagnoses listed in pathology reports and operative notes.
abstract: OBJECTIVE
  To compare surgeons' interpretations of intraoperative diagnoses with those rendered by the pathologist.
  
  
  METHODS
  Consecutive intraoperative diagnoses over a nine-month period were retrospectively reviewed. For each case, operative notes were obtained from the hospital information system. The intraoperative diagnoses listed in the final pathology reports were compared with those dictated by the surgeon. Discrepancies were stratified by potential clinical impact: category A, overall correct diagnosis with minor unimportant differences; category B, discrepant diagnosis with both either benign or malignant; and category C, intraoperative diagnoses differing between benign and malignant. The method of communication of each discrepant intraoperative diagnoses (in person vs telephone) was also examined.
  
  
  RESULTS
  There was no record of the intraoperative diagnoses in 20% of operative notes. Comparison of intraoperative diagnoses was possible in 1,131 cases. Category A errors were noted in 94 (8.3%) cases, B in 11 (1%), and C in 4 (0.3%). The most frequent means of communication in A and B cases was the telephone, with more C cases being relayed in person.
  
  
  CONCLUSIONS
  A subset of verbally reported intraoperative diagnoses is misinterpreted by surgeons. While rare events, miscommunication can lead to inappropriate intraoperative management. Communicating diagnoses by phone may increase the risk of perception errors.
authors.affiliation: Dept of Pathology and Microbiology, University of Nebraska Medical Center, 983135 Nebraska Medical Center, Omaha, NE 68198-3135.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Talmon
authors.forename: Adam
authors.initials: A
authors.lastname: Horn
authors.forename: Whitney
authors.initials: W
authors.lastname: Wedel
authors.forename: Ross
authors.initials: R
authors.lastname: Miller
authors.forename: Alison
authors.initials: A
authors.lastname: Stefonek
authors.forename: Travis
authors.initials: T
authors.lastname: Rinehart
mesh_terms: D003142:Communication; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D005260:Female; D005568:Forms and Records Control; D005629:Frozen Sections; D006801:Humans; D007430:Intraoperative Care; D007432:Intraoperative Period; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009870:Operating Room Information Systems; D010340:Pathology, Surgical / Q000379:methods / Q000592:standards; D015203:Reproducibility of Results
keywords: Communication; Frozen section; Quality management