Original Article

AVOIDABLE DEATHS: A SYSTEMATIC REVIEW ON CLINICAL DIAGNOSTIC DISAGREEMENTS AND AFTER AUTOPSIES

How to cite: Trunckle YF, Miziara CSMG, Muñoz DR, Miziara ID, Andreazzi IM. Mortes evitáveis: revisão sistemática sobre as discordâncias diagnósticas clínicas e após a realização de autópsias. Persp Med Legal Pericia Med. 2020; 5(1).

https://dx.doi.org/10.47005/050103

Submitted 11/10/2019
Accepted 11/20/2019

The authors declares that there is no conflict of interest.

MORTES EVITÁVEIS: REVISÃO SISTEMÁTICA SOBRE AS DISCORDÂNCIAS DIAGNÓSTICAS CLÍNICAS E APÓS A REALIZAÇÃO DE AUTÓPSIAS

Yuri Franco Trunckle (1)

Lattes: http://lattes.cnpq.br/2180059850861759 – ORCID: https://orcid.org/0000-0002-9133-9653

Carmen Silvia Molleis Galego Miziara (2)

Lattes: http://lattes.cnpq.br/6916238042273197 -ORCID: https://orcid.org/0000-0002-4266-0117

Daniel Romero Muñoz (1)

Lattes: http://lattes.cnpq.br/3863004771570436 -ORCID: https://orcid.org/0000-0002-4042-3070

Ivan Dieb Miziara (1)

Lattes: http://lattes.cnpq.br/3120760745952876 – ORCID: https://orcid.org/0000-0001-7180-8873

Ingryd Maturo Andreazzi (1)

Lattes: http://lattes.cnpq.br/8921241226597473 -ORCID: https://orcid.org/0000-0003-1478-7572

(1) Faculdade de Medicina da Universidade de São Paulo (FMUSP). (Main Author)

(2) Faculdade de Medicina do ABC e da Universidade Nove de Julho. (Main Author)

E-mail: yuriftrunckle@gmail.com

ABSTRACT

Introduction: avoidable deaths are those totally or partially preventable by the health service. Despite technological advances in health, studies have shown that there are clinical and post-mortem diagnostic divergences. This study aims to correlate the clinical and pathological diagnoses obtained through the analysis of studies already carried out in the literature, in order to determine the frequency with which the necropsy reveals unexpected diagnoses. Method: Systematic review of the literature by searching the MEDLINE database using the search strategy “Cause of Death” [Mesh]) AND “Medical Errors” [Mesh]) AND “Autopsy” [Mesh]. Results: Twenty-seven articles of retrospective studies and systematic reviews that met the inclusion criteria were included, with a variation from 6% to 82.3% of the diagnostic disagreements found. Conclusion: Although the indices vary, it can be inferred that there are diagnostic disagreements found in the retrospective studies and systematic reviews carried out until then, requiring a greater correlation with the litigation effects of poor medical practice.

Keywords: autopsy, diagnostic error displayed, causes of death.


Bibliographical references

1. Malta DC, Duarte EC, Almeida MF, Dias MAS, Morais Neto OL, Moura L et al. Lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epid Serv Saúde. 2007; 16(4): p233-244.
2. Muñoz DR, Muñoz-Gianvecchio D, Gianvecchio VAP. Momento histórico de uma especialidade. Saúde Ét Just. 2010; 15(2): p69-74.
3. Abate A. O erro médico. Neg Saúde. 2006; 35(1): p1-5.
4. Gonçalves CR. Responsabilidade civil. 14ed. São Paulo: Saraiva; 2012.
5. Santana SP. A culpa temerária: contributo para uma construção no direito penal brasileiro. São Paulo: Revista dos Tribunais; 2005.
6. Stedman. Dicionário Médico. 2003; p27.
7. Kanso S, Romero DE, Leite IC, Marques A. Brasil: análise das principais causas de morte. Cad Saúde Púb. 2013; 29(4): p735-774.
8. Laurenti R, Mello Jorge MHP, Gotlieb SL. A contabilidade dos dados de mortalidade e morbidade por doenças crônicas não-transmissíveis. Ciênc Saúde Col. 2004; 9(4): p909-921.
9. Mello Jorge MHP, Gotlieb SLD, Laurenti R. O sistema de informações sobre mortalidade: problemas e propostas para o seu enfrentamento I – Mortes por causas naturais. Rev Bras Epid. 2002; 5(2): p197-223.
10. Teixeira CLS, Klein CH, Bloch KV, Coeli CM. Reclassificação dos grupos de causas prováveis dos óbitos de causa mal definida, com base nas Autorizações de Internação Hospitalar no Sistema Único de Saúde, Estado do Rio de Janeiro, Brasil. Cad Saúde Púb. 2006; 22(6): p1315-1324.
11. Ministério da Saúde. Datasus. Brasília (DF); [s.d.] [citado jun. 2013]. Disponível em: www.datasus.gov.br.
12. Conterno LO, Barbosa RWN, Rego CM, Silva Filho CR. Gravidade do déficit neurológico e incidência de infecções em pacientes idosos com acidente vascular cerebral agudo. Sci Med. 2016; 26(4): ID25168.
13. Gnatta JR, Balsamo AC, Silveira IR, Padoveze MC. Características de pneumonias hospitalares em pacientes sem ventilação mecânica. J Infect Control 2014; 3(2): p32-35.
14. Jorge MHPM. Gastos governamentais do SUS com internações hospitalares por causas externas: análise no Estado de São Paulo em 2000. Rev Bras Epidemiol. 2004; 7(2): p228-238.
15. Brant LCC, Nascimento BR, Passos VMA, Duncan BB, Bensenõr IJM, Malta DC et al. Variações e diferenciais da mortalidade por doença cardiovascular no Brasil e em seus estados, em 1990 e 2015: estimativas do Estudo Carga Global de Doença. Rev Bras Epid. 2017; 20(1): p116-128.
16. Malta DC, Moura L, Prado RR, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epid Serv Saúde. 2014 out-dez; 23(4): p599-608.
17. Pereira KSM, Oliveira JCP, Carvalho FCC, Bellen BV. Complicações cardíacas em cirurgia vascular. J Vasc Bras. 2016; 15(1): p16-20.
18. Siqueira EMP, Diccini S. Complicações pós-operatórias em neurocirurgia eletiva e não eletiva. Acta Paul Enferm. 2017; 30(1): p101-108.
19. Almeida MC, Couto LAAM, Silva LHF, Carvalhal SS. Correlação diagnóstica anatomoclínica. Aferição retrospectiva do diagnóstico clínico em necropsias. Rev Saúde Públ. 1989; 23(4): p285-291.
20. Steigman CK. The autopsy as a quality assurance tool: last rites or resurrection? Arch Pathol Lab Med. 1996; 120: p736-738.
21. Roulson J, Benbow EW, Hasleton PS. Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review. Histop. 2005; 47(6): p551-559.
22. Liu D, Gan R, Zhang W, Wang W, Saiyin H, Zeng W et al. Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect? J Clin Pathol. 2018 Jan; 71(1): p67-71. doi: 10.1136/jclinpath-2017-204484. [Epub 2017 July 22[.
23. Issa VS, Dinardi LFL, Pereira TV, Almeida LK, Barbosa TS, Benvenutti LA et al. Diagnostic discrepancies in clinical practice: an autopsy study in patients with heart failure. Med. 2017; 96(4): e5978. doi:10.1097/MD.0000000000005978.
24. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983; 308: p1000-1005.
25. Sarode VR, Datta BN, Banerjee AK, Banerjee CK, Joshi K, Busnurmath B, Radotra BD. Autopsy findings and clinal diagnoses: A review of 1,000 cases. Hum Path. 1993; 24(2), p194-198.
26. Seftel MD, Ho M, Pruthi D, Orbanski S, Rubinger M, Schacter B, et al. High rate of discordance between clinical and autopsy diagnoses in blood and marrow transplantation. Bone Marrow Transp. 2007; 40: p1049-1053.
27. Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Arch Path Lab Med. 2017; 141(9): p1262-1266.
28. Pastores SM, Dulu A, Voigt L, Raoof N, Alicea M, Halpern NA. Premortem clinical diagnoses and post-mortem autopsy findings: discrepancies in critically ill cancer patients. Crit Care. 2007, 11(2): R48.
29. Silfvast T, Takkunen O, Kolho E, Andersson LC, Rosenberg P. Characteristics of discrepancies between clinical and autopsy diagnoses in the intensive care unit: a 5-year review. Intens Care Med. 2003; 29: p321-324
30. Mort TC, Yeston NS. The relationship of pre mortem diagnoses and post mortem findings in a surgical intensive care unit. Crit Care Med. 1999; 27(2): p299-303.
31. Tavora F, Crowder CD, Sun CC, Burke AP. Discrepancies between clinical and autopsy diagnoses: a comparison of university, community, and private autopsy practices. Am J Clin Pathol. 2008; 129(1): p102-109.
32. Spiliopoulou C, Papadodima S, Kotakidis N, Koutselinis A. Clinical diagnoses and autopsy findings: a retrospective analysis of 252 cases in Greece. Arch Pathol Lab Med. 2005; 129(2): p210-214.
33. O’Connor AE, Jeremy TP, Richardson DB, Jain S, Herdson PB. A comparison of the antemortem clinical diagnosis and autopsy findings for patients who die in the emergency department. Acad Emerg Med. 2002; 9(9): p957-959.
34. Perkins GD, McAuley DF, Davies S, Gao F. Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study. Crit Care 2003; 7: R129-R132.
35. Carvalho FLP, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study. Path Intern 2008; 58: p568-571.
36. Ornelas-Aguirre JM, Vázquez-Camacho G, Gonzalez-Lopez L, Garcia-Gonzalez A, Gamez-Nava JI. Concordance between premortem and postmortem diagnosis in the autopsy: results of a 10-year study in a tertiary care center. Ann Diag Path. 2003; 7(4): p223-230.
37. Tai DYH, El-Bilbeisi H, Tewari S, Mascha EJ, Wiedemann HP, Arroliga AC. A study of consecutive autopsies in a medical ICU* a comparison of clinical cause of death and autopsy diagnosis. Chest. 2001; 119(2): p530-536.
38. von Dessauer B, Velozo L, Benavente C, Bobenrieth F, Bongain J, Irazuzta J. Postmortem studies in the contemporary pediatric intensive care unit. Pediatr Crit Care Med. 2011; 12(6): p617-21. doi: 10.1097/PCC.0b013e3182071266.
39. Carlotti APCP, Bachette LG, Carmona F, Manso PH, Vicente WV, Ramalho FS. Discrepancies between clinical diagnoses and autopsy findings in critically Ill children: a prospective study. Am J Clin Pathol. December 2016; 146: p701-708.
40. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289(21): p2849-2856.
41. Coradazzi AL, Morganti ALC, Montenegro MRG. Discrepancies between clinical diagnoses and autopsy findings. Braz J Med Biol Res. 2003; 36: p385-391.
42. Casali MB, Mobilia F, Del Sordo S, Blandino A, Genovese U. The medical malpractice in Milan-Italy. A retrospective survey on 14 years of judicial autopsies. Forensic Sci Intern. 2014; 242: p38-43.
43. He F, Li L, Bynum J, et al. Medical malpractice in Wuhan, China: a 10 year autopsy-based single-center study.
44. Schwanda-Burger S, Moch H, Muntwyler J, Salomon F. Diagnostic errors in hte new millennium: a follow-up autopsy study. Mod Path. 2012; 25: p777-783.
45. Wittschieber D, Klauschen F, Kimmritz AC, von Winterfeld M, Kamphues C, Scholman HJ, et al. Who is at risk for diagnostic discrepancies? Comparison of pre- and postmortal diagnoses in 1800 patients of 3 medical decades in East and West Berlin. PLoS One. 2012; 7(5): e37460.