Intraoperative Diagnosis Miscommunication

Abstract

Intraoperative consultations/frozen section analyses are among the most stressful parts of a pathologist’s duties. By design they have a strict time limit, the sampling of a lesion may be insufficient, the histology is usually inferior to permanent sections, little or no ancillary studies are available, consultation is less likely to be available, the specimen may not be in the pathologist’s immediate area of expertise, and the clinical consequences may be quite significant. In addition, every mistake is likely to be identified by the leisurely Monday morning quarterback review of a wide array of permanent slides, ancillary studies, and consultations. Indeed, it is perhaps most impressive how few errors are actually made during intraoperative consultation. In this issue, Talmon et al1 point out yet another way in which an intraoperative consultation can go awry. In their study, they reviewed 1,131 intraoperative consultations and compared the written pathologist’s report with that dictated by the surgeon in the operative report. They found discrepancies in as many as 9.9% of cases, and in 0.3% of these cases, the discrepancies were between a benign and malignant …