Errors in cause-of-death statement on death certificates in intensive care unit of Kathmandu, Nepal

Abstract

BackgroundDeath certificates (DC) are one of the most important medico-legal documents that physicians work through. DCs are extensively used in health statistics for epidemiological studies, and in health policy planning as a public health resource tool. Cause-of-death (COD) statement, which is vulnerable to various errors, is the vital part of a DC that has the potential to mislead the policy makers and statisticians. Hence, we evaluated and analyzed the errors prevalent in COD statement of DC.MethodsA retrospective observational study was conducted at medical Intensive Care Unit (ICU) of Blue Cross Hospital, Kathmandu, Nepal within two years of study period. A total of 204 medical records of the deceased patients were reviewed. Three sub-headings of COD statement of DC- Part I Immediate COD (ICOD), Part I Underlying COD (UCOD), and Part II Other significant conditions (OSC) were extensively evaluated for the major medical errors.ResultsThe study found errors in 78.4 % of DCs. The highest number of errors was in UCOD (83 %). Most common errors were “Mechanism of Death- terminal event” in ICOD, “More than one competing causes” in UCOD, and “OSC present but not listed” in OSC. The error in DC was found to be statistically significant with the severity of sepsis (p = 0.003), and presence of chronic organ failures (p = 0.034). Age, time of death, source of admission, and duration of ICU stay were not found to be statistically associated with the errors in DC.ConclusionPrevalence of errors in DC was quite high. Most errors were committed in underlying cause of death, which is the most important part of DC. Complexity of the cases was the key factor that increased the risks of committing errors. Specific education should supersede general educational interventions to minimize the errors considerably in writing DC in complex cases.

Death Certification: Errors and Interventions

“…[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.…”

“…Both nationally and internationally, it has been reported that medical students and non-pathology residents are poorly trained in death certification. 1,4,[21][22][23] In one survey of 590 residents from various US institutions, 76% reported having received no formal training in death certification principals, and when asked to complete a cause of death statement based on a sample scenario of a hospital urosepsis death, 77% performed suboptimally, with 45% incorrectly attributing the death to a cardiovascular event. 21 At our institution, death certification inaccuracies cannot be attributed to resident inexperience per se, as only fellows and attending faculty are tasked with certification; however, the death certification training provided to trainees who ultimately become fellows and attending faculty is admittedly limited.…”

“…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.…”

“…Errors in death certification are common, with frequencies ranging from 17.7%-96% in hospital-based studies. [1][2][3][4][5] Errors occur even at institutions where autopsy pathologists trained in death certification are an available resource. Such errors can range in severity from spelling errors and incomplete demographic information to reporting the wrong cause and/ or manner of death altogether.…”

Death certificates errors in academic hospital; Review of 617 cases at Komfo Anokye Teaching Hospital (KATH), Kumasi

“…Furthermore, some studies have questioned the eligibility of house officers, residents, physician assistants and other trainees in death certification. These interns are temporal workers at health facilities and are likely to spend less time with patients in most cases (Maharjan et al, 2015). Studies conducted in Greece recorded more specialist and consultants than interns (Filippatos et al, 2016).…”