Fatal outcome after unintended events following medical intervention: a forensic pathological case survey

Abstract

Background:

There is an increasing focus on unintended events, sometimes fatal, following medical intervention. According to Danish law, unintended events following medical intervention and treatment must be reported to the DPSD (Danish Patient Safety Database).

Aim:

To estimate and describe the fatal cases of unintended events, as autopsied at the Forensic Institute of Copenhagen during 1 year.

Methods:

All case reports available were reviewed, and cases where the death could be a consequence of unintentional medical intervention, or lack of such, were selected. The autopsy findings, including the results of additional analyses were analyzed. To evaluate whether an unintentional event had preceded death, special attention was given to the sequence of events from 30 days before the death of the patient. Four groups of health personnel were defined in order to analyze the cases, as well as four types of unintended incidents: negligence; misjudgment of clinical symptoms; mistakes during invasive procedures or medical treatment, including medication errors; mistakes in care.

Results:

We found 98 fatal cases possibly following unintentional incidents in relation to medical intervention out of 720 autopsies. In these cases, hospital doctors were responsible for 60% of the total number of unintended events and for 84% of the fatalities related to mistakes happening during invasive procedures or medical treatment. Private practitioners and on-call doctors were represented in approximately equal numbers. The on-call doctors account for 30% and private practitioners for 10% of misjudgment of clinical symptoms. Infection was the most common cause of death followed by cardiovascular disease.

Conclusion:

We tried to formulate a brief checklist which could raise awareness for whether a fatality may be due to an unintended incident during a medical intervention. We propose the use of this checklist when issuing the death certificate, thus ensuring the correct reporting and further handling of the death.

Keywords::

• Denmark
• fatality
• hospital deaths
• doctors
• malpractice