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Editorials: H Guly More necropsies will improve patient care: has the case been made? Qual Saf Health Care 2005; 14: 397 [Full text] [PDF]

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Making the case for more necropsies to improve patient care

Megan A Bohensky, Joseph E Ibrahim, David L Ranson   (6 January 2006)

Making the case for more necropsies to improve patient care 6 January 2006
Megan A Bohensky, Research Officer Monash University, Joseph E Ibrahim, David L Ranson Send letter to journal: Re: Making the case for more necropsies to improve patient care meganb{at}vifm.org Megan A Bohensky, et al.	Dear Editor, In their recent study, Shojana et al highlight the importance of necropsy to clinical care by demonstrating how diagnostic sensitivity for three conditions is overestimated without necropsy results.[1] This study prompted an editorial by Guly calling for more research to demonstrate that increasing necropsy rates can improve patient care.[2] Clearly, the evidence establishing the value of necropsy for identifying diagnostic and management issues relevant to patient care[3] is not preventing the international decline in the number of hospital necropsies. Thus, we support Guly’s petition for more evidence and describe our efforts to improve communication between pathologists and clinicians to facilitate such research. At the Victorian Institute of Forensic Medicine, forensic necropsies are conducted on approximately 80% of hospital deaths investigated by the Coroner’s Office in Victoria, Australia.[4] A significant barrier to using the lessons of forensic necropsy for the improvement of clinical care is the lack of communication channels between Coroners and clinicians. The Clinical Liaison Service, which is the medical investigation unit assisting the State Coroners Office in Victoria, attempts to bridge the gap between Coroners and clinicians. Established in 2002, the Clinical Liaison Service reviews the hospital care of the deaths reported to the Coroner. This unit developed a standardized review process that integrates the necropsy results with the review of medical records to identify potential system failures in clinical practice. The review process includes a multi-disciplinary discussion with a Coroner, forensic pathologist, clinicians and coronial staff to determine which issues, if any, should be investigated further for the goal of system improvement and death prevention. Approximately 2,000 hospital deaths have been reviewed by the Clinical Liaison Service and twenty-five percent of these have undergone review at the multi- disciplinary discussion. At the conclusion of the investigation the Coroner makes a formal legal finding, that includes the issues of concern and recommendations to improve healthcare practice. As the Coroner’s recommendations are not always widely distributed,[5] the Clinical Liaison Service provides feedback to hospital staff to improve health professionals understanding of cases with patient safety implications. This feedback includes face to face presentations and a synopsis of noteworthy cases in the unit’s quarterly publication the Coronial Communiqué.[6] As the work by Shojana et al. shows, necropsy results have the capacity to impact clinical practice far more broadly than at the individual case level alone. In Victoria, a national database, the National Coroners Information System (NCIS), has been established to provide a national repository of information about each Coroner’s case, including the forensic necropsy report. It is vital that health researchers and clinicians consider the lessons from necropsy results in individual cases as well as in an aggregated form. Furthermore, their resulting information must be communicated widely or many valuable lessons may be overlooked. References 1. Shojania KG, Burton EC, McDonald KM, et al.Overestimation of clinical diagnostic performance rates caused by low necropsy rates. Qual Saf Health Care 2005;14:408–13. 2. Guly H. More necropsies will improve patient care: has the case been made? Qual Saf Health Care. 2005 Dec;14(6):397. 3. Darok M, Gatternig R, Mannweiler S. Late complications after medical treatment--malpractice or fate? Med Law. 2004;23(3):489-94. 4. Emmett SL, Ibrahim JE, Charles A, Ranson DL. Coronial autopsies: a rising tide of objections. Med J Aust. 2004 Aug 2;181(3):173. 5. Bugeja L, Ranson D. Coroners' recommendations: a lost opportunity. J Law Med. 2005 Nov;13(2):173-5. 6. Coronial Communique (http://www.vifm.org/communique.html)