Do Not Assume

Abstract

Sixty-six years ago, in a founding document of the computer age, the American engineer Claude Shannon1 charted information flow in his mathematical theory of communication. Figure 1 translates Shannon’s schematic diagram of a general communication system into the terms of surgical pathology’s information stream. Figure 1 Information flow in surgical pathology. An article in this issue of the Journal calls attention to the final step in the sequence. In this step, the surgical pathologist, decoder of signal, sends the diagnosis, the decoded signal, to its final destination, the pathology report. It is this message that a clinician integrates into a patient’s medical care.2 As Shannon1 demonstrated, all messages necessarily have a probability of error. Moreover, the greater a message’s information content, the more vulnerable is its communication to error.3 When decoders of the signal realize these errors, they usually resend a corrected version. Clinicians then have two reported signals between which to choose. This is the step in the information flow, between the re-decoded signal and its report, that Parkash and her colleagues2 studied. When they monitored amended report delivery, they found that 7 (12%) of 60 re-sent messages were sent to a person who turned out to have been the wrong destination. Parkash et al ascertained that the ordering provider, the recipient to which the re-sent, revised, message …