death certificates

Phillip Benton, MD, JD pgbentonmd at AOL.COM
Thu May 5 19:57:16 UTC 2016


Is such review not essentially what Lucien Leape and colleagues did in the Harvard Medical Practice study (N Engl J Med. 1991 Feb 7;324(6):377-84) 25 years ago, referenced in the IOM  report To Err Is Human (1999)? The several reviews that followed were systematically re-reviewed  by John James just 3 years ago (J Patient Saf. 2013 Sep;9(3):122-8.). 

Can we deny the problem?  NO.  Can we arrive at a consensus definition (wth qualifiers) and ascribe an ICD code (with modifiers)?  Most probably YES if anyone will take it on.

Phil Benton, MD, JD
Atlanta, GA

-----Original Message-----
From: Elizabeth Regan <lizregan53 at GMAIL.COM>
Sent: Thu, May 5, 2016 2:24 pm
Subject: [IMPROVEDX] death certificates

I would not favor adding medical error to death certificates for a variety of reasons but the chief one being that it is so hard to define and while is obvious to those who want to see improvement, it is less obvious to those who want to avoid the concept. At the point where there is broader consensus on how to identify and reduce medical error (especially diagnostic error) I think it will be easier to record and track the event.

I believe strongly that it is critical to do that, but we are not there yet.

I have just completed a project to adjudicate cause of death in nearly a 1000 deaths for a large cohort study. The project involves reviewing both death certificates and medical records. At that level of review I did not see evidence of diagnostic error or other errors. Now that I consider the project in light of this discussion - I guess that is interesting.

I don’t interpret this to mean that none of those subjects experienced error, but rather to reflect on the invisibility of error in our record keeping.

I wonder about the feasibility of re-reviewing the data with a more critical eye and finding more. However, I don’t really think I would find much.

Liz Regan

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