Death Certificates

Jackson, Brian brian.jackson at ARUPLAB.COM
Thu May 5 15:39:19 UTC 2016


Here are detailed instructions from CDC on how to fill out a death certificate:  http://www.cdc.gov/nchs/data/dvs/blue_form.pdf  And a more detailed explanation of the “manner of death” section can be found at http://snohomishcountywa.gov/806/Cause-Manner-of-Death

If a death certificate is properly filled out, and if a medical error directly caused the death, then the cause of death should be listed as the error event and the manner of death should be listed as “Accident”.  When the error is diagnostic in nature, rather than therapeutic, then then the error should probably be listed as a contributing rather than the immediate cause.

About 20 years ago when I was a pathology resident, I performed an autopsy of a man who died as a consequence of a surgical complication.  The man had a massive cancerous prostate which had caused urinary obstruction.  The urologist attempted to open up the urethra via scope, but encountered significant difficulty and ended up perforating the bladder without realizing it.  Within hours the patient went downhill and died, and the urologist immediately suspected a perforation.  He encouraged the family to consent to autopsy where I was able to confirm what happened.

I don’t know what conversation took place between the urologist and the family.  This was at a VA, but it may have been a little before the VA system formally institutionalized medical error acknowledgement.  What I do know is that my attending pathologist insisted in listing the manner of death as “Natural” and the cause of death as “Prostate cancer”  on the death certificate.  I didn’t think this was correct but didn’t see a way to challenge it.

--Brian Jackson

From: Joe Graedon [mailto:jgraedon at GMAIL.COM]
Sent: Thursday, May 05, 2016 8:19 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Death Certificates

There is another pretty serious flaw in the system.

The CDC seems quite unwilling to add medical error to its current list of conditions leading to death. Here is the “official” response to Marty Makary’s BMJ article:

"Bob Anderson, chief of the mortality statistics branch for the CDC, disputed that the agency’s coding is the problem. He said complications from medical care are listed on death certificates, and that codes do capture them. The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment.
As a result, even if a doctor does list medical errors on a death certificate, they are not included in the published totals. Only the underlying condition, such as heart disease or cancer, is counted, even when it isn’t fatal.
Anderson said the CDC’s approach is consistent with international guidelines, allowing U.S. death statistics to be compared with those of other countries. As such, it would be difficult to change “unless we had a really compelling reason to do so,” Anderson said.”

I interpret that to mean… “no one else is doing it so why should we?” There is no compelling reason to change. Really?

Bottom line: If an ED physician misdiagnoses alpha-gal allergy as a stomach “bug” and sends a patient home with Imodium and the patient dies from anaphylactic shock, the death certificate will say death from anaphylaxis. That would be the way the CDC would include such a death in its list of conditions. No where would there be an acknowledgement that the person died from 1) misdiagnosis of tick-related allergic reaction or 2) inappropriate treatment.

And since this person would have died at home it would not even be included in hospital statistics.

Makary points out that his 250,000 number underestimates the problem because it does not include outpatient mistakes/deaths, nursing home mistakes/deaths or ambulatory care surgical centers. We have calculated the number of iatragenic deaths at over 700,000…making health care harm the # 1 cause of death in the U.S. Anyone who would like to see how we arrived at that number can find documentation in “Top Screwups Doctors Make and How to Avoid Them.”

http://www.amazon.com/Screwups-Doctors-Make-Avoid-Them/dp/0307460924/ref=sr_1_1?ie=UTF8&qid=1462457632&sr=8-1&keywords=top+screwups+doctors+make+and+how+to+avoid+them

Joe


On May 5, 2016, at 11:35 AM, Robert Bell <rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>> wrote:

And would changing the culture of medicine only occur if litigation law was changed? If litigation law WAS changed would we then collect all data relating to error? It seems we cannot do much for error reduction until we collect good data - or am I wrong? Do we need to prove we can improve?

So is perennial talk without action what we are saddled with for ALL time?

Could a deal be made with national and local governments and also the legal community and public to be excused heavy litigation costs so long as data was collected, and errors were being reduced and controlled? Or any other creative suggestion that might work?

Yes, somehow we need to break through the impenetrable wall of resistance by changing the culture of medicine as Joe mentions. Surely, surely we can come up with a way forward?

Rob Bell

Sent from my iPad

On May 5, 2016, at 5:35, Joe Graedon <jgraedon at gmail.com<mailto:jgraedon at gmail.com>> wrote:
This is a very interesting concept.

Just out of curiosity, has anyone ever asked the question or sought an answer to the question:

How many times does "Error in Diagnosis" show up on death certificates? If I were a betting person I would guess rare to never.

As to the second "Error in Medicine" I would guess never.

To change that one would need to change the culture of medicine.

Joe

Sent from my iPad

On May 4, 2016, at 11:11 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
It is not common practice to put either Error in Diagnosis, or Error in Medicine on a death certificate. They seem to require some kind of diagnosis even if it may be incorrect.

Could this Society change that with action and recommendations or would you have to first change litigation law to achieve that?

Are there any other solutions that would be acceptable?

This would seem to be part of that data lack that plagues the Error in Medicine discipline.

Robert M. Bell, M.D., Ph.C.



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