Post-Mortem Examination as a Quality Improvement Instrument

Abstract

ver since G. B. Morgagni (1) first showed the scientific value of autopsies, many reasons have arisen for carrying out autopsies over the centuries (2). Despite the manifold indications for autopsy, however, over the past few decades autopsy rates have been falling all over the world, and so they have in Germany. Opinions vary as to what lies behind this drop in autopsy rates. Our own experience, based on many interviews and conversations, suggests that many doctors, especially young ones, believe that clinical findings and causes of death can be adequately investigated using available clinical diagnostic techniques, so that autopsies have become unnecessary. This view is contradicted, however, by many publications showing that discrepancies continue to exist between pre-mortem and post-mortem diagnoses. In this article, we discuss alternatives to the "classical" autopsy. The clinical autopsy: definition and indicationsA clinical autopsy is a macroscopic medical examination by a physician of (if possible) all three body cavities of a deceased person, supplemented by clinical information relating to the medical history, cause of death, and clinical questions (Box 1).Discrepancies between pre-mortem and postmortem diagnoses are of varying significance for the treatment of the patient and are usually classified according to the Goldman criteria (3): • Class I error: Misdiagnosis that may have affected survival and probably would have required alteration of treatment • Class II error: Misdiagnosis that did not affect survival and would not have required alteration of treatment • Class III and class IV errors: Missed minor diagnoses unrelated to the disease course Discrepancies between pre-mortem and postmortem diagnosesSince 1912, up to 2002 and even later, numerous studies have shown considerable differences between pre-and post-mortem diagnoses (Table 1) (4-13, e2-e5).In 2003, a literature search by Shojania et al. ( 14) for the period 1966 to 2002 identified a total of 45 studies (53 different autopsy series). Irrespective of methodological problems, which they discussed, these authors reached the following conclusions: On average, the rate of class I errors was 9% (range: 0 to Summary Background: Autopsies are considered an important quality assurance instrument in medicine, yet autopsy rates in many countries have been declining for many years. The proper role of the post-mortem examination in modern medicine is a matter deserving of study.Methods: This review is based on a selective search of the literature for publications on the role of autopsies as a quality assurance instrument.Results: Multiple studies have revealed substantial rates of discrepancy between pre-and post-mortem diagnoses, with reported rates lying in the range of 10% to 40%. The frequency of so-called Goldman I erroneous diagnoses, i.e., those that are determined at autopsy and might have influenced the patient's survival, ranges from 2.4% to 10.7%. It can be assumed that the rate of serious diagnostic errors revealed by autopsy would fall i...

The autopsy at the time of SARS-CoV-2: Protocol and lessons

“…The autopsy ascertains the cause of death both in hospitalized patients and in people who died without medical assistance, transported to hospital or in a morgue. Last, but not least, the autopsy is a valid aid for training and education of clinicians themselves [1][2][3]. In recent months we have witnessed the emergency of a new global threat, the SARS-CoV-2, which produced a new disease (COVID-19) that quickly turned into a pandemic.…”

Sepsis-3: new edition — old problems. analysis from the perspective of general pathology

“…По-видимому, авторы не дифференцируют понятие «органно-тканевое повреждение» от «органная дисфункция». Кроме того, непонятно, как септикопиемия (наличие вторичных очагов инфекции) характеризует патогенез сепсиса в отсутствие органной дисфункции, тем более если это касается внутренних органов, где пиемические очаги в ряде случаев могут выявляться только при патологоанатомическом исследовании [55]. Конечно, не вызывает сомнения, что в большинстве случаев пациенты с септикопиемией нуждаются в интенсивной терапии в условиях ОРИТ.…”

Clinical and Anatomical Comparisons in Assessing the Quality of Medical Care

“…Согласно метаанализу публикаций по использованию системы Гольдмана [17], обычно частота расхождений диагнозов колеблется в пределах 10-40 %. Частота расхождений класса I (по нашей системе это 3-я категория расхождений) колеблется в интервале 2,4-10,7 %.…”