Elsevier

Injury

Volume 36, Issue 8, August 2005, Pages 976-983
Injury

Missed diagnoses in trauma patients vis-à-vis significance of autopsy

https://doi.org/10.1016/j.injury.2004.09.025Get rights and content

Summary

Post-mortem examination is considered to be the gold standard for the critique of medical practice, providing a quality control tool for the retrospective evaluation of diagnoses and treatment. Performing autopsies also facilitates new insight about the pathogenesis of disease and effects of therapy, gives feedback to clinical research protocols, provides epidemiological information and occasionally helps to console and reassure grieving families that death was inevitable. Its significance becomes paramount in cases of missed diagnosis in trauma-related deaths. The true incidence of missed diagnoses in trauma-related deaths is unknown, because autopsy is conducted in only about 50% of injury-related deaths. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. The present study is an attempt to evaluate the incidence and nature of missed injuries and complications in trauma-related deaths given an autopsy rate of close to 100%. This study also sought to identify the primary factors contributing to each missed injury. However, the study is in no way intended to assigning blame to human or system errors. Rather, it is focussed specifically on the issue of whether autopsy can be useful to provide feedback in identifying clinical problems of trauma patients.

Introduction

Management of trauma patients with multiple injuries can be one of the most clinically challenging situations faced by even the most seasoned health care workers. In the acute management of the trauma patient, injuries may be missed during initial assessment. Clear guidelines, as outlined by the Advanced Trauma Life Support Course2 dictate strict priorities in the initial management of the polytraumatised patient and help minimise the incidence of missed injuries. A rapid primary survey to immediately identify and manage life-threatening injuries followed by a detailed head-to-toe secondary survey is the standard of care in trauma management. The concept of a tertiary trauma survey was introduced by Enderson et al.15 to identify injuries missed after the primary and secondary survey performed in the resuscitation room. However, despite these efforts, it is recognised that many injuries/complications can still entirely escape detection in the hospital.14 Several variables, both patient- and physician-related, have been identified as being associated with an increased likelihood of unrecognised injuries.7, 22, 32 According to a study, reviewed autopsy reports of trauma patients revealed a 34% incidence of missed injuries.1

The consequences of missed diagnoses in trauma-related deaths have been well described in the literature.27, 36, 37, 38 More recent studies3, 12, 21, 23, 31 report an incidence of 0–15% of missed diagnoses among all trauma patients contributing to death. Missed diagnoses, in addition to being potential sources of morbidity and mortality, may also represent varying degrees of clinical inexperience. The lack of extensive studies on this subject may be partly attributed to a general reluctance of clinicians to admit and account for their errors. However, in an increasingly litigious society, where public demands for accountability within the health care system are becoming the norm, it is important to provide an open forum for examination when patient management is questioned.

Furthermore, the autopsy rate in the United States has been reported to be declining during the past three decades.18, 28 This decline has been attributed to lack of time, lack of interest and a perception of a differing diagnosis after death as a physician failure. The role of autopsy in detecting missed injuries in the trauma population is well described,4, 34 but because the autopsy rate being only about 50% for trauma deaths, the true incidence of missed diagnosis is unknown. Trauma patients in the intensive care units (ICU) represent a unique challenge: diagnostic dilemmas are frequent because a large number of patients have altered consciousness or are mechanically ventilated. Consequently, few studies have specifically addressed missed injuries among trauma patients in the ICU.8, 13, 26

Section snippets

Material and methodology

This retrospective study was conducted at the Department of Forensic Medicine and Toxicology, Government Medical College and Hospital Chandigarh—a Tertiary Care Centre, catering for the health and medical needs of the city, having a population of over one million people and a referral centre for the adjoining states. Trauma victims subjected to medico-legal autopsy during the years 2000–2003, whose detailed history and case records were available, were the subjects of our study. Unclaimed,

Epidemiology (Tables 1–3)

Over a 4-year period, 11792 trauma patients were treated at Government Medical College Hospital Chandigarh. Of the trauma patients, 1034 (9%) sustained penetrating injuries, 7850 (67%) had blunt injuries and 2908 (25%) had received burns (Table 1). A total of 749 (6%) patients died with 249 (39%) deaths occurring in the ICU/Trauma ward. Of these, 163 (21.76%) had a survival period of more than twenty-four hours. Vehicular accidents were the main cause of trauma 426 cases, followed by burns 264

Discussion

The autopsy has the potential to provide an educational tool for health care providers. Despite its value in assessing quality of medical care, the autopsy rate in the United States for all causes of deaths has been reported to be 10–20% for the last 15–20 years.28 Furthermore, it has been shown to vary inversely with the age. According to a report, the autopsy rate for the deaths in a medical ICU was 60% for those aged 16–34 years and 23% for those aged 85 or more.6 The autopsy rate of

Conclusion

Missed diagnosis during initial assessment and diagnostic workup is a hard reality in a small yet significant number of trauma patients. The majority of such missed injuries are attributable to potentially avoidable factors with inadequate clinical assessment often referred to as the clinical error. Some of these injuries escape detection on secondary or even the tertiary trauma surveys and are detected only on autopsy. Autopsy thus continues to be a valuable tool for accurate data collection

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