How well do we communicate?: a comparison of intraoperative diagnoses listed in pathology reports and operative notes

To compare surgeons' interpretations of intraoperative diagnoses with those rendered by the pathologist.

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.

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.

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.