D'Errico Stefano, Zanon Martina, Peruch Michela, Concato Monica, Padovano Martina, Santurro Alessandro, Scopetti Matteo, Fineschi Vittorio
Department of Medicine, Surgery, and Health, University of Trieste, Strada di Fiume 44, 34149 Trieste, Italy.
Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00185 Rome, Italy.
Diagnostics (Basel). 2021 Aug 9;11(8):1436. doi: 10.3390/diagnostics11081436.
Over the last 50 years, the number of clinical autopsies has decreased, but their role in assessing cause of death and clinical performance is still acknowledged. Few publications have studied their role in malpractice claim prevention. The paper aims to highlight the role of clinical autopsy in preventing errors and improve healthcare quality. A retrospective study was conducted on 28 clinical autopsies performed between 2015 and 2021 on patients dead unexpectedly after procedures for the diagnosis and treatment of digestive and hepatic diseases. After an accurate analysis of medical records and consultation with healthcare professionals, all cases were subjected to autopsy and histopathology. The data obtained were analyzed and shared with the risk-management team to identify pitfalls and preventive strategies. Post-mortem evaluations confirmed the clinical diagnosis only in six cases (21.4%). Discordances were observed in 10 cases (35.7%). In the remaining 12 cases (42.9%) the clinical diagnosis was labeled as "unknown" and post-mortem examinations made it possible to document the cause of death. Post-mortem examinations can concretely enrich hospital prevention systems and improve patient safety. The methodological approach outlined certainly demonstrates that, even in the risk-management field, "mors gaudet succurrere vitae" ("death delights in helping life").
在过去50年里,临床尸检的数量有所减少,但它们在评估死因和临床诊疗表现方面的作用仍得到认可。很少有出版物研究它们在预防医疗事故索赔方面的作用。本文旨在强调临床尸检在预防失误和提高医疗质量方面的作用。对2015年至2021年间对因消化和肝脏疾病诊断及治疗程序后意外死亡的患者进行的28例临床尸检进行了回顾性研究。在对病历进行准确分析并咨询医疗专业人员后,所有病例均进行了尸检和组织病理学检查。对获得的数据进行分析,并与风险管理团队分享,以识别潜在问题和预防策略。尸检评估仅在6例(21.4%)中证实了临床诊断。在10例(35.7%)中观察到诊断不一致。在其余12例(42.9%)中,临床诊断被标记为“不明”,尸检使得记录死因成为可能。尸检可以切实丰富医院预防系统并提高患者安全。所概述的方法学方法无疑表明,即使在风险管理领域,“死亡乐于帮助生命”(“mors gaudet succurrere vitae”)。