Catastrophic breaches in patient safety often involve point-of-care settings such as the operating theater or intensive care unit, quite frequently without due consideration given to the elements leading up to such errors. Among such occurrences, wrong site procedures (WSPs) and diagnostic discrepancies continue to result in significant morbidity and mortality among patients. Addressing adverse events is difficult for all stakeholders involved. Furthermore, clinician familiarity with the workflow specific to particular disciplines or procedures may be poor, amplifying communication lapses that precede patient safety occurrences. The patient care paradigm has become increasingly multidisciplinary, and it is important to discuss, improve, and be more cognizant of measures required to achieve “zero defect” performance. Despite the rarity of “never events,” their consequences may damage patient and community trust, provider morale, and institutional reputation. This chapter aims to assess current preventive measures and risks in the context of errors involving surgical pathology in the setting of the operating theater utilizing the framework of clinical vignettes. The discussion below will further center on the practical and interpretative errors that occur in the pathological workflow, and the potential for compounding of such errors in the operating theater. Definitions concerning WSP and diagnostic discrepancies will be outlined to characterize potential outcomes of communication errors.
Part of the book: Vignettes in Patient Safety