Department of Forensic Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
Int J Qual Health Care. 2010 Feb;22(1):9-15. doi: 10.1093/intqhc/mzp058. Epub 2009 Dec 2.
To determine the incidence of potential medical adverse events among patients undergoing forensic autopsy, and to present the characteristics of potential medical adverse events.
Retrospective review of consecutive autopsy records.
Department of Forensic Medicine, the Jikei University School of Medicine, Tokyo, Japan.
A total of 3355 forensic autopsy cases between 1983 and 2006.
Incidence of potential medical adverse events identified in decedents undergoing forensic autopsy, classified by actual occurrence as 'confirmed', 'equivocal' and 'negative' cases; proportion of potential diagnostic, performance and system errors among potential medical adverse events.
Of 291 autopsies (8.7%) with potential medical adverse events, 66 cases (22.7%) were confirmed, 42 cases (14.4%) were negative and 183 cases (62.9%) were equivocal. Confirmed cases consisted of potential diagnostic errors in 49 cases (74.2%) and performance errors in 17 cases (25.8%). Equivocal cases included 99 cases associated with potential diagnostic errors (54.1%) and 60 cases associated with potential system errors (32.8%). In 38 of the confirmed cases (57.5%), serious exacerbation of patient condition occurred outside the medical facility.
Potential medical adverse events are not uncommon in decedents undergoing forensic autopsy. They are particularly associated with potential diagnostic errors. Forensic autopsy may provide information that could be used to improve care and reduce deaths due to potential medical adverse events.
确定接受法医解剖患者潜在医疗不良事件的发生率，并介绍潜在医疗不良事件的特征。
连续法医解剖记录的回顾性审查。
日本东京顺天堂大学医学院法医系。
1983 年至 2006 年间共 3355 例法医解剖案例。
法医解剖患者中潜在医疗不良事件的发生率，按实际发生情况分为“确诊”、“疑似”和“阴性”病例；潜在医疗不良事件中潜在诊断、表现和系统错误的比例。
291 例（8.7%）潜在医疗不良事件中，66 例（22.7%）确诊，42 例（14.4%）阴性，183 例（62.9%）疑似。确诊病例中，49 例（74.2%）为潜在诊断错误，17 例（25.8%）为性能错误。疑似病例中，99 例与潜在诊断错误相关（54.1%），60 例与潜在系统错误相关（32.8%）。在 38 例确诊病例（57.5%）中，患者病情严重恶化发生在医疗机构之外。
接受法医解剖的死者中潜在医疗不良事件并不少见。它们特别与潜在诊断错误有关。法医解剖可以提供可能用于改善护理和减少潜在医疗不良事件导致的死亡的信息。
