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LETTERS: Tuan V Nguyen, Ken M Hillman, Michael D Buist, S Chakraverty, J Wright, Rosalind Plowman, Jennifer A Roberts, Nicholas Graves, Mark A S Griffin, Barry Cookson, Lynda Taylor, Brian T Collopy, I G McDonald, David Griffith, Paul Diggory, Anand Mehta, Charles Vincent, Graham Neale, Maria Woloshynowych, R E Ferner, J K Aronson, and Stephen Bezruchka Adverse events in British hospitals BMJ 2001; 322: 1425 [Full text]

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Reporting Medical Errors Must take into Account Autopsy Results

James Sington, Barry Cottrell   (29 June 2001)

Reporting Medical Errors Must take into Account Autopsy Results 29 June 2001
James Sington, Specialist Registrar in Cellular pathology / Consultant Histopathologist John Radcliffe Hospital, Oxford / Addenbrooke's Hospital, Cambridge, Barry Cottrell Send response to journal: Re: Reporting Medical Errors Must take into Account Autopsy Results	Editor – In response to recent correspondence by authors relating to issues of medical error, organ retention and death certification, we wish to communicate the results of our study comparing causes of death on death certificates to those found at autopsy.(1) On examining 440 hospital autopsies from a tertiary teaching hospital centre and comparing the cause of death to those on the death certificate, we found substantial discrepancies. The sensitivity of the death certificate in predicting the cause of death was 0.47. There was a range across systems with the highest sensitivity in the neurological system (0.90) and the lowest in the cardiovascular system (0.28). Interestingly, sensitivity for all malignant causes of death on the certificate was only 0.65, and we found that in 35% of overdiagnosed malignant deaths, no tumour was demonstrated at autopsy. Our data is in accordance with similar studies which demonstrate a significant divergence in cause of death recorded on the death certificate and those found at autopsy. Divergence rates of up to 75% for previously undisclosed and clinically important findings are reported.(2) Despite the dramatic improvements in radiological imaging and diagnostic technology, autopsy is still considered to be the gold standard for determining the cause of death.(3) Nevertheless the rate of hospital autopsies has fallen dramatically, and in many hospitals is well below the recommended level of 10% of all hospital deaths. It follows from this that the accuracy and reliability of any current mortality data must be viewed with caution. The lamentable decline in hospital based request autopsies has resulted from a combination of complex factors which must include rather negative perceptions of both the medical profession and the general public. We are in little doubt that matters have been made significantly worse by an overburdening consent process, and media-hyped exploitation of issues relating to the retention of organs. We consider that a lack of willingness of the general public and medical profession alike to acknowledge the continuing benefit of hospital autopsies, as demonstrated by their widely understated decrease in number, should be addressed urgently, especially if the public is to be reassured of a system where discrepancies and medical errors can be discussed, and clinical performance monitored openly. In the recent paper by Vincent (4) and editorial by Alberti,(5) neither mention the role of the autopsy in the collection of corroborative evidence in medical error reporting. Vincent states that 8% of medical errors contributed to death, and this data was obtained by review of patient notes. They suggest a widening of this approach to discover the real incidence of medical error. However, before instigating such huge and expensive administrative schemes it seem foolhardy to let the gold standard of autopsy to whither on the vine. If the current decline in autopsy rate continues, we risk losing a vital tool for the audit of clinical practise and a means of an accurate compilation of epidemiological data. References 1. Sington J, Cottrell B. Analysis of the Sensitivity of Death Certificates in 440 Hospital Deaths - A Comparison with Autopsy Findings. J Clin Pathol 2001 (In Press). 2. Laissue J-A, Altermatt HJ, Zurcher B et al. The significance of the autopsy: evaluation of current autopsy results by the clinician. Schweiz Med Wschr 1986; 116:130-134. 3. Goldman L, Sayson R, Robbins S et al. The value of autopsy in three medical eras. N Engl J Med 1983; 308:1000-5. 4. Vincent C, Neale G, Woloshynnowych. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-519. 5. Alberti KGMM. Medical errors: a common problem. BMJ 2001;322:501-502.