Potential medical adverse events associated with death: A forensic pathology perspective

International Journal for Quality in Health Care

Volumn 22, Issue 1, 2009, Pages 9-15

  Sakai, Kentaro ^a   Takatsu, Akihiro ^b   Shigeta, Akio ^c   Fukui, Kenji ^a   Maebashi, Kyoko ^a   Abe, Shuntaro ^a   Iwadate, Kimiharu ^a  

^a JIKEI UNIVERSITY SCHOOL OF MEDICINE   (Japan)

^b Research Center for Medical Sciences   (Japan)

^c Tokyo Medical Examiner's Office   (Japan)

Author keywords

Adverse event; Forensic autopsy; Malpractice claim; Medical error; Medical malpractice

Indexed keywords

ADOLESCENT; ADULT; ADVERSE OUTCOME; AGED; ARTICLE; AUTOPSY; CHILD; CONTROLLED STUDY; DIAGNOSTIC ERROR; DISEASE EXACERBATION; FEMALE; FORENSIC PATHOLOGY; HEALTH CARE FACILITY; HUMAN; INFANT; JAPAN; MALE; MALPRACTICE; MEDICAL ERROR; PRESCHOOL CHILD; PRIORITY JOURNAL; SCHOOL CHILD; SYSTEM ERROR;

EID: 77952580483     PISSN: 13534505     EISSN: 14643677     Source Type: Journal    
DOI: 10.1093/intqhc/mzp058     Document Type: Article

References (37)

1. Weiler PC, Hiatt HH, Newhouse JP et al. A Measure of Malpractice: Medical Injury, Malpractice Litigation, and Patient Compensation. Cambridge: Harvard University Press, 1993.
2. Studdert DM, Mello MM, Gawande AA et al. Medical malpractice. N Engl J Med 2004;350:283-92.
3. Dettemeyer R, Egl M, Madea B. Medical malpractice charges in Germany - role of the forensic pathologist in the preliminary criminal proceeding. J Forensic Sci 2005;50:423-7.
4. National Practitioner Data Bank. Healthcare Integrity and Protection Data Bank Annual Report 2006. Available at:http://www.npdb-hipdb.hrsa.gov/annualrpt.html (28 February 2009, date last accessed).
5. Taragin MI, Wilczek AP, Kams ME et al. Physician demographics and the risk of medical malpractice. Am J Med 1992;93:537-42.
6. White AA, Pichert JW, Bledsoe SH et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 2005;105:1031-8.
7. Morris JA Jr, Carrillo Y, Jenkins JM et al. Surgical adverse events, risk management, and malpractice outcome: morbidity and mortality review is not enough. Ann Surg 2003;237:844-51.
8. Rosenblat RA, Hurst A. An analysis of closed obstetric malpractice claims. Obstet Gynecol 1989;74:710-4.
9. Carroll AE, Buddenbaum JL. Malpractice claims involving pediatricians: epidemiology and etiology. Pediatrics 2007;120:10-7.
10. Cheney FW, Posner K, Caplan RA et al. Standard of care and anesthesia liability. J Am Med Assoc 1989;261:1599-603.
11. Taragin MI, Willet LR, Wilczek AP et al. The influence of standard care of injury on the resolution of medical malpractice claims. Ann Intern Med 1992;117:780-4.
12. Baker T. Reconsidering the Harvard Medical Practice Study conclusions about the validity of medical malpractice claims. J Law Med Ethics 2005;33:501-14.
13. Brennan TA, Leape LL, Laird N et al. Incidence of adverse events and negligence in hospitalized patients: result of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
14. Leape LL, Brennan TA, Laird N et al. The nature of adverse events in hospitalized patients: result of the Harvard Medical Practice Study II. New Engl J Med 1991;324:377-84.
15. Thomas EJ, Studdert DM, Burstin HR et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
16. Wilson RM, Runciman BW, Gibberd RW et al. The quality in Australian health care study. Med J Aust 1995;163:458-71.
17. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press, 2000.
18. Quality Interagency Coordination Task Force. Doing What Counts For Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact: Report of the Quality Interagency Coordination Task Force (QuIC) to the President, Washington, DC: US Department of Health and Human Services, Agency for Healthcare Research and Quality, 2000.
19. Furuse A. What we must learn from recent medical accidentsexperiences at the investigation committee. Gan To Kagaku Ryoho 2001;28:310-6 (in Japanese).
20. Tokyo Medical Examiner's Office. Annual report 2008, Tokyo, 2009 (in Japanese).
21. The Project for The Investigation of Death Associated with Medical Practice. The Summary of Report of Evaluated Cases. http://www.med-model.jp/all.php (20 December 2008, date last accessed) (in Japanese).
22. Shojania KG, Burton EC, McDonald KM et al. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. J Am Med Assoc 2003;289:2849-56.
23. Perkins GD, McAuley DF, Davies S et al. Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study. Crit Care 2003;7:R129-R132.
24. Aalten CM, Samson MM, Jansen PA. Diagnostic errors; the need to have autopsies. Neth J Med 2006;64:186-90.
25. Podbregar M, Voga G, Krivec B et al. Should we confirm our clinical diagnostic certainty by autopsies? Intensive Care Med 2001;27:1750-5.
26. Twigg SJ, McCrirrick A, Sanderson PM. A comparison of post mortem findings with post hoc estimated clinical diagnoses of patients who die in a United Kingdom intensive care unit. Intensive Care Med 2001;27:706-10.
27. Goldman L, Sayson R, Robbins S et al. The value of the autopsy in three medical eras. N Engl J Med 1983;308:1000-5.
28. Newton D, Coffin CM, Clark EB et al. How the pediatric autopsy yields valuable information in a vertically integrated health care system. Arch Pathol Lab Med 2004;128: 1239-46.
29. Muthaq F, Ritchie D. Do we know what people die of in the emergency department? Emerg Med J 2005;22:718-21.
30. Spiliopoulou C, Papadodima S, kotakidis N et al. Clinical diagnoses and autopsy findings: a retrospective analysis of 252 cases in Greece. Arch Pathol Lab Med 2005;129:210-4.
31. Goldstein B, Metlay L, Cox C et al. Association of pre mortem diagnosis and autopsy findings in pediatric intensive care unit versus emergency department versus ward patients. Crit Care Med 1996;24:683-6.
32. Kumar P, Taxy J, Angst DB et al. Autopsies in children: are they still useful? Arch Pediatr Adolesc Med 1998;152:558-63.
33. Kumar P, Angst D, Taxy J et al. Neonatal autopsies: a 10-year experience. Arch Pediatr Adolesc Med 2000;154:38-42.
34. Ermenc B. Comparison of the clinical and post mortem diagnoses of the cause of death. Forensic Sci Int 2000;114: 117-9.
35. Seow E, Lau G. Who dies at A&E? The role of forensic pathology in the audit of mortality in an emergency medicine department. Forensic Sci Int 1996;82:201-10.
36. Weingart SN, Wilson RM, Gibberd WR et al. Epidemiology of medical error. BMJ 2000;320:774-7.
37. Tanigawa K, Tanaka K. Emergency medical service systems in Japan: past present, and future. Resuscitation 2006;69:365-70.