Medical Errors Detected at the Autopsy: A Prelude to Avoiding Malpractice Litigations

Abstract

Background: Diagnostic errors arising from wrong clinical judgments and conclusions are common occurrences worldwide in routine medical practice. Unfortunately, it results in unpleasant clinical sequelae such as unnecessary complications and premature deaths. Many of these cases pass undetected except post-mortem examination is conducted. The clinical post-mortem examination is gradually becoming extinct, partly due to over-reliance by clinicians on modern technology-driven diagnostic facilities. This study exhibits the role of the post-mortem examination in unravelling the errors of clinical management that resulted in death. Knowing the possibilities of these errors would be a prelude to avoid litigations as physicians endeavour to put structures in place to prevent them. Materials and Methods: A retrospective review of one hundred (100) full post-mortem dissections done, were comprehensively analysed. The ages of patients and the errors of judgment were noted. Attention was paid to the diagnoses missed, complications undetected and the crucial contributions of the complications and diagnoses missed to death. Results: Out of one hundred (100) post-mortem examinations, thirty-six (36, 36%) cases showed instances of medical errors as detected by the autopsy. Twenty-two (22) were males while fourteen (14) were females signifying a male predominance in a male to female ratio of 1.6:1. The bulk of the cases were seen from the third to the seventh decades of life. There were 4 cases of missed congenital disorders, 11 cases of missed infections, 8 cases of missed malignancies, 1 case of missed acquired cystic lesion and 1 case of missed head injury. Two infections were misdiagnosed as malignancies, 2 cases of infections misdiagnosed in the same organ, 2 cases of infections were diagnosed in the wrong systems, 14 cases of infections were completely missed, 4 cases of cancers were diagnosed in the wrong organ, 6 cases showed missed complications of hypertension. There was a case of critical omission involving elective induction of labour; resulting in ruptured uterus with concomitant massive intra-abdominal haemorrhage and intrauterine foetal death. Conclusion: The post-mortem examination remains the gold standard for unravelling controversial deaths arising from clinical management. Autopsies should be duly conducted when indicated and structures put in place to examine corpse statutorily when deaths occur in unexpected circumstances. These findings would help clinicians to be wiser for the next patient and prevent future embarrassment from litigations.