References: Burying Mistakes; Volume 3 Issue 9

1. AUTHOR	Hasson-J.
INSTITUTION	Department of Anatomic Pathology, University of Connecticut Health Center, USA.
TITLE	Medical fallibility and the autopsy in the USA.
SOURCE	J-Eval-Clin-Pract 1997 Aug, VOL: 3 (3), P: 229-34, ISSN: 1356-1294 38 Refs.
ABSTRACT	The theory of 'necessary fallibility', originated by Gorovitz & Mac Intyre (1976, In Science, Ethics and Medicine, Hastings Center, NY), explains a major unfamiliar reason for unavoidable errors in medicine. A brief historical review is presented of autopsy studies assessing the accuracy of clinical diagnoses, and of changing perceptions of the public and physicians leading to the current misconception in the USA that all errors are avoidable. It is suggested that a prospective autopsy study is needed to test the theory of 'necessary fallibility'. Validation of this theory would benefit an understanding of medical fallibility by the public and physicians, and challenge current practices in the management of malpractice and patient injury. Author.

2. AUTHOR	Britton-M.
TITLE	Diagnostic errors discovered at autopsy.
SOURCE	Acta-Med-Scand 1974 Sep, VOL: 196 (3), P: 203-10, ISSN: 0001-6101.

3. AUTHOR	Britton-M.
TITLE	Clinical diagnostics: experience from 383 autopsied cases.
SOURCE	Acta-Med-Scand 1974 Sep, VOL: 196 (3), P: 211-9, ISSN: 0001-6101.

4. AUTHOR	Goldman-L, Sayson-R, Robbins-S, Cohn-L-H, Bettmann-M, Weisberg-M.
INSTITUTION	Department of Medicine, Brigham and Women's Hospital, Boston, MA.
TITLE	The value of the autopsy in three medical eras.
SOURCE	N-Engl-J-Med 1983 Apr 28, VOL: 308 (17), P: 1000-5, ISSN: 0028-4793.
ABSTRACT	To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care. Author.

5. AUTHOR	Anderson-R-E, Hill-R-B, Key-C-R.
INSTITUTION	Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM 87131.
TITLE	The sensitivity and specificity of clinical diagnostics during five decades. Toward an understanding of necessary fallibility (see comments).
SOURCE	JAMA 1989 Mar 17, VOL: 261 (11), P: 1610-7, ISSN: 0098-7484 35 Refs.
CM	Comment in: JAMA 1989 Jul 21; 262(3):350-1.
ABSTRACT	Published studies encompassing more than 50,000 autopsies were assessed to determine the sensitivity and specificity of clinical diagnostics (the diagnostic process) in persons dying of 1 of 11 specific diseases during the period 1930 through 1977. The accuracy of clinical diagnostics, as reflected in these two determinations, appeared to improve over this period with respect to some of the diseases studied (rheumatic heart disease and leukemia), while for others it worsened (pulmonary tuberculosis, peritonitis, carcinoma of the lung, gastric carcinoma, and carcinoma of the liver and extrahepatic biliary tract) and for a significant number diagnostic accuracy seemed refractory to sustained change (pulmonary embolism, primary cirrhosis of the liver, gastric/peptic ulcer, and acute coronary thrombosis/myocardial infarction). The findings suggest a new way in which the autopsy can be used to monitor clinical diagnostics to identify possible sources of systematic weaknesses and provide data that can be used to approach the difficult subject of necessary fallibility. Author.