Is hospital autopsy auditing suitable for clinical risk management? Actualities and perspectives of auditing in the autopsy room following Italian Law 24/2017 on patient safety

BACKGROUND: autopsies are a valuable tool for understanding the physiopathology of a disease and it is the gold standard to assess the cause of death. The clinical autopsy is the ultimate medical service for a patient and plays a crucial role in the context of quality control, education of physicians and other medical personnel, as well as mitigation of risk of malpractice claims.OBJECTIVE: This study aims to demonstrate the importance of improving an autopsy service and the relevance of this investigation procedure in daily clinical practice by evaluating the rate of major discrepancies between the assumed cause of death and the ascertained cause of death after a complete post mortem investigation. A further aim is to classify these discrepancies as class I or class II discrepancies according to Goldman's criteria in order to asses performance quality.METHODS: a retrospective study of the hospital autopsies performed from June 2018 to March 2020 was conducted by considering a diversified dataset, including age and sex of the deceased as well as the clinical and pathological causes of death.RESULTS: 362 cases were taken into consideration. Major discrepancies were found in 71.3% of cases, with a class I error of 22.7% and a class II error of 48.6%. The most frequent misdiagnoses were cardiovascular disorder, embolism and aneurism rupture.DISCUSSION: The rate of major discrepancies and the rate of class I and class II errors are way above the rate found in literature. Despite the high rate of major discrepancy evidences collected from hospital autopsies (i.e. certainty of the cause of death, unknown comorbidities) strengthened the legal defense in cases of medical malpractice litigation. In our experience, by accurately determining the cause of death, revealing new or unexpected findings and possible diagnostic or technical errors, postmortem examinations can significantly contribute to the improvement of team performance and quality of care.CONCLUSION: The presence of clinicians during autopsy and the early sharing of results can be considered a new auditing strategy for hard clinical cases. Finally, by providing a clearer understanding of the nature and cause of the illness, the autopsy results assisted in the grieving process by reassuring family members that action or inaction on their part had not contributed to the death.