Autopsy-detected diagnostic errors over time in the intensive care unit

Tejerina, Eva; Padilla, Rebeca; Abril, Elena; Frutos‐Vivar, Fernando; Ballen, Aida; Rodríguez-Barbero, J.M.; Lorente, José A.; Esteban, Andrés

doi:10.1016/j.humpath.2018.02.025

Cited by 29 publications

(30 citation statements)

References 32 publications

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“…However, it is likely that the suddenness of the outbreak, the number of patients in hospitals, the shortage of healthcare personnel, and the high rate of transmissions [13] may significantly reduce the number of autopsies and sampling from cadavers. Clinical value of autopsy is also supported by several studies demonstrating that despite the introduction of more modern diagnostic techniques and of intensive and invasive monitoring, the number of missed major diagnoses has not essentially changed over the past 20 to 30 years; autopsies revealed ante mortem diagnostic errors or ante mortem unrecognized diagnoses in about 30% of cases [2,14].…”

Section: Discussionmentioning

confidence: 95%

COVID-19 Deaths: Are We Sure It Is Pneumonia? Please, Autopsy, Autopsy, Autopsy!

Pomara

Volti

Cappello

2020

JCM

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The current outbreak of COVID-19 severe respiratory disease, which started in Wuhan, China, is an ongoing challenge, and a major threat to public health that requires surveillance, prompt diagnosis, and research efforts to understand this emergent pathogen and to develop an effective response. Due to the scientific community's efforts, there is an increasing body of published studies describing the virus' biology, its transmission and diagnosis, its clinical features, its radiological findings, and the development of candidate therapeutics and vaccines. Despite the decline in postmortem examination rate, autopsy remains the gold standard to determine why and how death happens. Defining the pathophysiology of death is not only limited to forensic considerations; it may also provide useful clinical and epidemiologic insights. Selective approaches to postmortem diagnosis, such as limited postmortem sampling over full autopsy, can also be useful in the control of disease outbreaks and provide valuable knowledge for managing appropriate control measures. In this scenario, we strongly recommend performing full autopsies on patients who died with suspected or confirmed COVID-19 infection, particularly in the presence of several comorbidities. Only by working with a complete set of histological samples obtained through autopsy can one ascertain the exact cause(s) of death, optimize clinical management, and assist clinicians in pointing out a timely and effective treatment to reduce mortality. Death can teach us not only about the disease, it might also help with its prevention and, above all, treatment.

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Section: Discussionmentioning

confidence: 95%

COVID-19 Deaths: Are We Sure It Is Pneumonia? Please, Autopsy, Autopsy, Autopsy!

Pomara

Volti

Cappello

2020

JCM

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“…[13][14][15][16] Autopsy remains the standard against which clinician death certification accuracy is assessed. 3,[1][2][3][4][5][6][7][8][9][10][11][12][17][18] Despite many diagnostic medical advances, recent studies still report autopsy to reveal major missed diagnoses in roughly 17.7%-29% of cases. 3,[17][18][19] Even in cases in which autopsy was not performed, review of death certificates and corresponding medical records by autopsy pathologists reportedly reveals certification errors in up to 48%¬96% of cases, of which 34%-51% are major errors.…”

Section: Discussionmentioning

confidence: 99%

“…3,[1][2][3][4][5][6][7][8][9][10][11][12][17][18] Despite many diagnostic medical advances, recent studies still report autopsy to reveal major missed diagnoses in roughly 17.7%-29% of cases. 3,[17][18][19] Even in cases in which autopsy was not performed, review of death certificates and corresponding medical records by autopsy pathologists reportedly reveals certification errors in up to 48%¬96% of cases, of which 34%-51% are major errors. 2,11,20 These results are comparable to those seen in our series; 85% of the non-pathologist physician completed death certificates at our institution contained one or more errors; of these, 52% contained major missed diagnoses.…”

Section: Discussionmentioning

confidence: 99%

“…2 Currently, there is no commonly accepted grading scheme to categorize the type and severity of death certification errors, though some models have been previously proposed. [1][2][3][4][5]11,18,20 In devising the grading scale used in our study, we elected not to categorize grammatical, spelling, handwriting, abbreviation use, or lack of time interval specification in Part I/II as errors. Although such clerical errors may signify inexperience or carelessness on the part of the medical certifier, the overall impact was viewed as limited when compared to substantive errors regarding the cause and manner of death.…”

Section: Discussionmentioning

confidence: 99%

“…Conversely, errors regarding the manner of death were entirely omitted from the data reported in several studies. 1,[3][4][5]18,20 Because errors in manner of death may have severe legal implications and would definitely warrant an amendment to the death certificate, these errors were incorporated into our grading scale as the most severe error type (ie., grade V error). We found addressing comorbidities that contributed to death to be one of the more challenging aspects of designing a grading scale, due to the fact a single comorbidity could be considered either major or minor depending on the unique clinical circumstances of that case.…”

Section: Discussionmentioning

confidence: 99%

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Death Certification: Errors and Interventions

2019

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Death certificates are legal documents containing critical information. Despite the importance of accurate certification, errors remain common. Estimates of error prevalence vary between studies, and error classification systems are often unclear. Relatively few studies have assessed the frequency at which death certification errors occur in US hospitals, and even fewer have attempted a standardized classification of errors based on their severity. In the current study, our objective was to evaluate the frequency of death certification errors at an academic center, implement a standardized method of categorizing error severity, and analyze sources of error to better identify ways to improve death certification accuracy. Design: We retrospectively reviewed the accuracy of cause and manner of death certification at our regional academic institution for 179 cases in which autopsy was performed between 2013-2016. We compared non-pathologist physician completed death certificates with the cause and manner of death ultimately determined at autopsy. Methods: Errors were classified via a 5-point scale of increasing error severity. Grades I-IIc were considered minor errors, while III-V were considered severe. Sources of error were analyzed. Results: In the majority of cases (85%), death certificates contained ≥ one error, with multiple errors (51%) being more common than single (33%). The most frequent error type was Grade 1 (53%), followed by Grade III (30%), and Grade IIb (18%). The more severe Grade IV errors were seen in 23% of cases; no Grade V errors were found. No amendments were made to any death certificates following finalization of autopsy results during the study period. Conclusion: This study reaffirms the importance of autopsy and autopsy pathologists in ensuring accurate and complete death certification. It also suggests that death certification errors may be more frequent than previously reported. We propose a method by which death certification errors can be classified in terms of increasing severity. By understanding the types of errors occurring on death certificates, academic institutions can work to improve certification accuracy. Better clinician education, coordination with autopsy pathologists, and implementation of a systematic approach to ensuring concordance of death certificates with autopsy results is recommended.

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