Error Prevention in Transcription and Report Distribution
Historically, surgical pathology reports have been manually transcribed following dictation. More recently, voice recognition technology has been employed with or without the use of templates for common specimens. Required cancer reporting protocols are often combined with both manual transcription and voice recognition technology approaches. Errors observed in both approaches are discussed. Concurrently, there has been an evolution from manual/paper pathology report distribution into the patient’s physical chart to inclusion of the report in the patient’s comprehensive electronic health record. Data that crosses an electronic interface between a laboratory information system and an electronic health record is subject to loss of fidelity or formatting alterations which may render a final product different from what the pathologist originally intended. Inclusion of diagrams and/or photomicrographs with surgical pathology reports is possible in some systems, but can add a layer of complexity to successful electronic report distribution. Finally, some thought must be applied to the distribution of information within an individual pathology report for maximum interpretability. This chapter discusses errors that can arise in the transcription and distribution of diagnostic data in pathology reports. Strategies for assessment and prevention of these errors in real practice situations are provided.
