Intraoperative communications between pathologists and surgeons: do we understand each other?

Amanda Wiggett; Gabor Fischer

Study

Intraoperative communications between pathologists and surgeons: do we understand each other?

September 6, 2023

Wiggett A, Fischer G. Arch Pathol Lab Med. 2023;147(8):933-939.

View more articles from the same authors.

Miscommunication between pathologists and surgeons can lead to significant patient harm. This study identified multiple discrepancies between pathologist-listed diagnoses included in intraoperative consult notes compared to surgeon-dictated operative notes. Discrepancies were most common in multipart cases and those involving deferrals.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Responsible e-prescribing needs e-discontinuation.

February 15, 2017

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

November 10, 2010

Supervision, autonomy, and medical error in the teaching clinic.

January 9, 2019

Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study.

February 6, 2019

The 2011 duty-hour requirements—a survey of residency program directors.

February 27, 2013

Residents' response to duty-hour regulations—a follow-up national survey.

June 6, 2012

Rapid response teams as a patient safety practice for failure to rescue.

July 7, 2021

Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.

December 8, 2010

Discussion of medical errors in morbidity and mortality conferences.

March 6, 2005

Matching nurse skill with patient acuity in the intensive care units: a risk management mandate.

July 5, 2006

Measuring patient safety in the emergency department.

June 19, 2013

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

June 29, 2011

Beyond medication reconciliation: the correct medication list.

May 3, 2017

Abusive supervision: a systematic review and fundamental rethink.

December 8, 2021

Second opinions improve healthcare outcomes and reduce costs.

June 24, 2020

Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study.

October 27, 2021

A growth mindset approach to preparing trainees for medical error.

April 26, 2017

The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations.

March 16, 2022

Diagnostic errors by medical students: results of a prospective qualitative study.

December 13, 2017

Teaching and medical errors: primary care preceptors' views.

October 12, 2005

Clinic design for safety during the pandemic: safety or teamwork, can we only pick one?

May 11, 2022

Approval and perceived impact of duty hour regulations: survey of pediatric program directors.

October 23, 2013

The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events.

July 7, 2021

Learning from mistakes: factors that influence how students and residents learn from medical errors.

May 24, 2006

Factors influencing preceptors' responses to medical errors: a factorial survey.

October 19, 2005

A concept analysis of situational awareness in nursing.

April 17, 2013

The "July phenomenon": is trauma the exception?

October 14, 2009

A simulation-based approach to training in heuristic clinical decision-making.

June 19, 2019

Deaths among opioid users: impact of potential inappropriate prescribing practices.

May 15, 2019

Influence of perioperative handoffs on complications and outcomes.

November 17, 2021

Diagnostic error in pediatric cancer.

January 17, 2018

How patients perceive a doctor's caring attitude.

September 24, 2008

Disclosure of medical errors: what factors influence how patients respond?

June 21, 2006

A qualitative exploration of the impact of a distressed family member on pediatric resuscitation teams.

October 7, 2020

The lost sponge: patient safety in the operating room.

October 17, 2012

An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety?

January 29, 2014

Using nurses and office staff to report prescribing errors in primary care.

May 7, 2008

Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity.

June 6, 2007

Moving beyond implicit bias in antiracist academic medicine initiatives.

September 7, 2022

Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne, Australia.

June 27, 2007

Primary medication non-adherence: analysis of 195,930 electronic prescriptions.

February 17, 2010

Transitioning between electronic health records: effects on ambulatory prescribing safety.

May 4, 2011

Changing smart pump vendors: lessons learned.

December 14, 2016

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project.

February 13, 2013

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience.

July 13, 2011

When no news is bad news: improving diagnostic testing communication through patient engagement.

March 9, 2022

Incidence of medication errors and adverse drug events in the ICU: a systematic review.

September 15, 2010

Attitudes to patient safety amongst medical students and tutors: developing a reliable and valid measure.

October 28, 2009

Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents.

July 29, 2015

Perception of patient safety culture in pediatric long-term care settings.

February 13, 2019

Pharmacist medication reviews to improve safety monitoring in primary care patients.

May 18, 2016

The Daily Plan: including patients for safety's sake.

April 11, 2012

Patient safety indicators for judging hospital performance: still not ready for prime time.

February 24, 2016

Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes.

May 10, 2023

Are personal health records (PHRs) facilitating patient safety? A scoping review.

June 15, 2022

Analysis of laboratory critical value reporting at a large academic medical center.

May 24, 2006

Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study.

July 5, 2023

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

August 18, 2021

Impact of patient safety culture on missed nursing care and adverse patient events.

March 20, 2019

Nearing zero...reducing grade C medication errors.

July 23, 2014

Caregiver and clinician perspectives on discharge medication counseling: a qualitative study.

July 12, 2023

ACGME duty-hour recommendations—a national survey of residency program directors.

August 11, 2010

Filling the gap: simulation-based crisis resource management training for emergency medicine residents.

May 2, 2018

Assessment of teamwork during structured interdisciplinary rounds on medical units.

October 31, 2012

Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.

May 29, 2019

Association of interruptions with an increased risk and severity of medication administration errors.

May 5, 2010

Frequency of HIV-related medication errors and associated risk factors in hospitalized patients.

April 2, 2008

The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question.

June 28, 2023

Is there evidence of a July effect among patients undergoing hysterectomy surgery?

October 10, 2018

Point-of-care cognitive support technology in emergency departments: a scoping review of technology acceptance by clinicians.

July 18, 2018

Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit.

November 6, 2013

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

February 3, 2021

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

March 13, 2013

Influence of gender, profession, and managerial function on clinicians' perceptions of patient safety culture: a cross-national cross-sectional study.

June 9, 2021

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

March 2, 2011

Medical emergency teams: a strategy for improving patient care and nursing work environments.

June 28, 2006

Implementation and impact of a rapid response team in a children's hospital.

July 11, 2007

Patient engagement in health care safety: an overview of mixed-quality evidence.

November 28, 2018

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

March 14, 2012

Nurses' satisfaction with medication administration point-of-care technology.

September 5, 2007

Effect of different interventions to help primary care clinicians avoid unsafe opioid prescribing in opioid-naive patients with acute noncancer pain: a cluster randomized clinical trial.

September 7, 2022

Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.

August 5, 2020

Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens.

November 26, 2014

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Sources of medication omissions among hospitalized older adults with polypharmacy.

March 9, 2022

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

August 11, 2010

Is communication improved with the implementation of an obstetrical version of the World Health Organization safe surgery checklist?

November 9, 2016

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

May 24, 2017

Lost information during the handover of critically injured trauma patients: a mixed-methods study.

December 16, 2015

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue.

November 11, 2020

Association between measured teamwork and medical errors: an observational study of prehospital care in the USA

December 11, 2019

Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy.

November 20, 2019

Clinical outcomes associated with medication regimen complexity in older people: a systematic review.

June 28, 2017

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital.

August 22, 2007

Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study.

May 17, 2006

Unintentional discontinuation of chronic medications for seniors in nursing homes: evaluation of a national medication reconciliation accreditation requirement using a population-based cohort study.

July 8, 2015

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients.

September 28, 2016

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.

November 15, 2017

Related Resources

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

September 6, 2023

Error traps in pediatric patient blood management in the perioperative period.

September 6, 2023

How does robotic-assisted surgery change OR safety culture?

September 6, 2023

Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

June 21, 2023

Cognitive bias and dissonance in surgical practice: a narrative review.

April 26, 2023

WebM&M Cases

Procedure Complications – Who is Responsible for Follow up?

March 29, 2023

A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis.

November 2, 2022

WebM&M Cases

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.

October 27, 2022

Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology.

October 5, 2022

Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture.

August 31, 2022

ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

August 24, 2022

Patterns of error in interpretive pathology.

August 17, 2022

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.

June 29, 2022

WebM&M Cases

Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest

January 26, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

January 11, 2022

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

December 22, 2021

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

WebM&M Cases

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

August 25, 2021

Reducing surgical specimen errors through multidisciplinary quality improvement.

June 16, 2021

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study.

May 26, 2021

Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study.

August 12, 2020

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

Impact of staff turnover during cardiac surgical procedures.

February 12, 2020

Error Reduction and Prevention in Surgical Pathology, Second Edition.

August 28, 2019

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

WebM&M Cases

Good Catch in the Operating Room

May 1, 2019

Learning From Invited Reviews.

April 10, 2019

Reducing diagnostic errors worldwide through diagnostic management teams.

April 3, 2019

Measuring the rate of manual transcription error in outpatient point-of-care testing.

March 13, 2019

See More About The Topic

Operating Room

Pathology and Laboratory Medicine

Surgery

Diagnostic Test Interpretation Error

Intraoperative Complications

Intraoperative communications between pathologists and surgeons: do we understand each other?

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Intraoperative communications between pathologists and surgeons: do we understand each other?

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site