From the Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada (Wiggett, Fischer).
Shared Health Manitoba, Diagnostic Services, Pathology, Winnipeg, Manitoba, Canada (Wiggett, Fischer).
Arch Pathol Lab Med. 2023 Aug 1;147(8):933-939. doi: 10.5858/arpa.2020-0632-OA.
CONTEXT.—: Clear communication between pathologists and surgeons during intraoperative consultations is critical for optimal patient care.
OBJECTIVE.—: To examine the concordance of intraoperative diagnoses recorded in pathology reports to surgeon-dictated operative notes and assess the impact of an intervention on the discrepancy rates.
DESIGN.—: Discrepancies between the intended communication by pathologists and the interpretation by surgeons were characterized as minor with no crucial clinical impact, and major with the potential of altering patient management. After analysis, a corrective intervention was implemented with education, information sharing, and a change in protocol, and a comparative analysis was conducted.
RESULTS.—: We examined 223 surgical cases with 578 intraoperative consultations. In 23% (51) of the cases, the intraoperative diagnosis was not recorded in the operative reports. We found minor discrepancies in 34% (59) and major discrepancies in 2% (3) of the remaining cases. Deferrals accounted for 24% (14 of 59) of the minor and 33% (1 of 3) of the major discrepancies. Among the discrepant cases, 56% (35 of 62) were multipart cases, including all major discrepancies. Following intervention, no major discrepancies were found in 101 cases with 186 intraoperative interpretations. The cases with no operative documentation reports decreased from 23% to 16% (16 of 101). Minor discrepancies were found in 11% (9 of 85) of the cases, indicating significant improvement (P < .001).
CONCLUSIONS.—: Intraoperative diagnoses can be miscommunicated and/or misinterpreted, possibly impacting intraoperative management, particularly in multipart cases and those involving deferrals. This study highlights the importance of auditing intraoperative communications and addressing the findings through a local intervention.
病理学家和外科医生在术中会诊时进行清晰的沟通对患者的最佳护理至关重要。
检查病理报告中记录的术中诊断与外科医生口述的手术记录之间的一致性，并评估干预措施对差异率的影响。
将病理学家的预期沟通与外科医生的解释之间的差异特征描述为对临床管理没有重大影响的次要差异，以及可能改变患者管理的主要差异。在分析后，实施了纠正干预措施，包括教育、信息共享和改变方案，并进行了比较分析。
我们检查了 223 例手术病例和 578 次术中会诊。在 23%（51 例）的病例中，术中诊断未记录在手术报告中。我们发现，在其余病例中，有 34%（59 例）存在轻微差异，2%（3 例）存在主要差异。推迟诊断占 24%（59 例中的 14 例）的轻微差异和 33%（3 例中的 1 例）的主要差异。在存在差异的病例中，56%（62 例中的 35 例）为多份病例，包括所有主要差异。干预后，在 101 例有 186 次术中解释的病例中未发现主要差异。无手术记录报告的病例从 23%降至 16%（101 例中的 16 例）。11%（85 例中的 9 例）的病例存在轻微差异，表明显著改善（P<0.001）。
术中诊断可能会出现沟通和/或解释错误，可能会影响术中管理，尤其是在多份病例和涉及推迟诊断的病例中。本研究强调了审核术中沟通的重要性，并通过本地干预措施解决发现的问题。
