Discrepancies between clinical diagnosis and hospital autopsy: A comparative retrospective analysis of 1,112 cases

Correlations and discrepancies between cardiac ultrasound, clinical diagnosis and the autopsy findings in early deceased patients with suspected cardiovascular emergencies

Cardiac ultrasound (CUS), either focused cardiac ultrasound (FoCUS) or emergency echocardiography, is frequently used in cardiovascular (CV) emergencies. We assessed correlations and discrepancies between CUS, clinical diagnosis and the autopsy findings in early deceased patients with suspected CV emergencies. We retrospectively analysed clinical and autopsy data of 131 consecutive patients who died within 24 h of hospital admission. The type of CUS and its findings were analysed in relation to the clinical and autopsy diagnoses. CUS was performed in 58% of patients - FoCUS in 83%, emergency echocardiography in 12%, and both types of CUS in 5% of cases. CUS was performed more frequently in patients without a history of CV disease (64 vs. 40%, p = 0.08) and when the time between admission and death was longer (6 vs. 2 h, p = 0.021). In 7% of patients, CUS was inconclusive. In 10% of patients, the ante-mortem cause of death could not be determined, while discrepancies between the clinical and post-mortem diagnosis were found in 26% of cases. In the multivariate logistic regression model, only conclusive CUS [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.30-7.39, p = 0.044] and chest pain at presentation (OR 30.19, 95%CI 5.65 -161.22, p < 0.001) were independently associated with congruent clinical and autopsy diagnosis. In a tertiary university hospital, FoCUS was used more frequently than emergency echocardiography in critically ill patients with suspected cardiac emergencies. Chest pain at presentation and a conclusive CUS were associated with concordant clinical and autopsy diagnoses.

Assessment of misdiagnosis in small animal intensive care patients using the Modified Goldman criteria

The postmortem examination can be used as a means of quality control for clinical diagnoses. A retrospective study on 300 dogs and cats that had been admitted to a small animal intensive care unit was performed comparing the clinical and postmortem findings, using the Modified Goldman criteria. All patient files were reevaluated for clinical diagnoses and all postmortem material was reevaluated for pathological diagnoses. After this, the Modified Goldman criteria were applied to score the discrepancies between them, and factors associated with the occurrence of an undiagnosed major unexpected finding were analyzed. The postmortem examination revealed additional findings in 65% of the cases. Major discrepancies, defined as those affecting treatment and possibly outcome of the patient, were present in 21.3% of the cases. The most frequently missed diagnoses detected at necropsy were pneumonia of various etiologies, meningitis/meningoencephalitis, myocarditis and generalized vasculitis. A shorter ICU stay was associated with increased odds of a major discrepancy. Conditions affecting the urinary or gastrointestinal system were negatively associated with major discrepancy.

Error codes at autopsy to study potential biases in diagnostic error

OBJECTIVES

Current autopsy practice guidelines do not provide a mechanism to identify potential causes of diagnostic error (DE). We used our autopsy data registry to ask if gender or race were related to the frequency of diagnostic error found at autopsy.

METHODS

Our autopsy reports include International Classification of Diseases (ICD) 9 or ICD 10 diagnostic codes for major diagnoses as well as codes that identify types of error. From 2012 to mid-2015 only 2 codes were used: UNDOC (major undocumented diagnoses) and UNCON (major unconfirmed diagnoses). Major diagnoses contributed to death or would have been treated if known. Since mid-2015, codes included specific diagnoses, i.e. undiagnosed or unconfirmed myocardial infarction, infection, pulmonary thromboembolism, malignancy, or other diagnosis as well as cause of death. Adult autopsy cases from 2012 to 2019 were assessed for DE associated with reported sex or race (nonwhite or white). 528 cases were evaluated between 2012 and 2015 and 699 between 2015 and 2019.

RESULTS

Major DEs were identified at autopsy in 65.9 % of cases from 2012 to 2015 and in 72.1 % from 2015 to 2019. From 2012 to 2015, female autopsy cases showed a greater frequency in 4 parameters of DE, i.e., in the total number of cases with any error (p=0.0001), in the number of cases with UNDOC errors (p=0.0038) or UNCON errors (p=0.0006), and in the relative proportions of total numbers of errors (p=0.0001). From 2015 to 2019 undocumented malignancy was greater among males (p=0.0065); no other sex-related error was identified. In the same period some DE parameters were greater among nonwhite than among white subjects, including unconfirmed cause of death (p=0.035), and proportion of total error diagnoses (p=0.0003), UNCON diagnoses (p=0.0093), and UNDOC diagnoses (p=0.035).

CONCLUSIONS

Coding for DE at autopsy can identify potential effects of biases on diagnostic error.

The autopsy is not dead: ongoing relevance of the autopsy

Background

Autopsy requests have been trending downward for a variety of factors. There are differences between pre- and postmortem diagnoses. Autopsies remain a tool for education, public health research, quality control, and closure for families.

Objective

We report two cases that illustrate the utility of autopsy for uncovering contributing factors in the death of these patients and highlight their ongoing importance.

Design

Clinical and autopsy investigation of two individuals and illustration of the importance of autopsy findings which, had they been diagnosed premortem, could have changed the outcome. Cases were evaluated using the Goldman criteria for discrepancies between premortem clinical diagnoses and postmortem autopsy findings.

Results

In the first case, the patient had been previously admitted due to a non-ST elevation myocardial infarction months before the fatal event. The autopsy showed an undiagnosed clear cell carcinoma of the ovary. She expired due to a massive myocardial infarction secondary to neoplasm induced hypercoagulable state. The degree of pre-mortem/postmortem diagnostic discrepancy makes this a Goldman Class I error.In the second case, the patient presented to the emergency department with symptoms of Guillain-Barré Syndrome (GBS), for which he was treated. Abdominal masses were discovered; however, the patient decompensated before workup was completed. A high-grade B-cell lymphoma was confirmed but would not have altered the outcome, making this a Goldman class II error.

Conclusions

The autopsy remains a relevant and necessary tool for physicians and society. It assists in the establishment of diagnoses, measurement of treatment quality, the providence of public health metrics, and closure to the survivors.

A Comprehensive Review of Pathological Examination in Forensic Medicine: Past, Present, and Future

Pathological examination (PE) encompasses a gross or macroscopy and histopathological or microscopic examination. It is prudent in finding the cause of death (COD) in clinical and medicolegal autopsies. There are various auxiliary techniques in the form of clinical history, communication, specialized training, and protocols for consolidation of the PE results. After a thorough search of the literature in PubMed with relevant keywords along with further analysis of the results, it emerged that even with the modernization of forensic medicine, a PE is unbeatable in detecting the COD. It has various useful aspects, apart from regular finding the COD, such as in student teaching, epidemiology of disease, audit tool, and quality assurance. There are also limitations of PE, which should be dealt with great caution. Hence, limitations must be understood by a forensic expert as well as a pathologist. In this review, all factors that are related to PE in any manner are discussed in detail, and the scope for improving the quality of PE to be relevant in the present scenario is reviewed. It is a comprehensive reassessment of the literature review that also casts light on the future along with a critical analysis of the facts that deal with PE.

[Adverse events associated with medical care, or the dark side of health care in foreign countries: a systematic review]

A systematic review is devoted to epidemiology of adverse events in short-stay hospitals in foreign countries. It is found that dualism is an important feature of medical care, since treatment results can be not only useful, but also harmful (adverse events) associated with medical care per se. Adverse events are diagnosed in 10.68% of patients. Moreover, complications occur at previous stages of treatment in 20.91% of cases. Incidence of adverse events is 2 times higher in surgical departments and intensive care units compared to therapeutic departments. Among all adverse events, 42.83% are associated with open surgery, 16.17% with drug therapy, and 14.10% with manipulations or minimally invasive interventions. Preventable adverse events caused by human factor account for 48.24%. In other cases, adverse events are the result of side effects of medical technologies, exposure to physical environment and unsafe patient behavior. Infection associated with medical care (28.15%) prevails among other adverse events. In 51.45% of cases, adverse events are characterized by mild harm and do not prolong hospital-stay. Moderate harm requiring additional in-hospital treatment develops in 31.80% of cases. In 11.89% of cases, adverse events are life-threatening complications and/or cause disability. Moderate-to-severe harm increases hospital-stay by 8.7 days. Incidence of adverse events followed by unfavorable outcomes is 5.25%. Overall mortality and mortality from adverse events are 6.67% and 0.55%, respectively. Deaths associated with adverse events account for one in five deaths in a hospital and one in ten deaths in population of developed countries.