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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Clifford F Hughes Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Butany, J. W Articles by Hughes, C. F Search for Related Content PubMed Articles by Butany, J. W Articles by Hughes, C. F

The Autopsy and Quality Assurance

Toronto General Hospital 200 Elizabeth Street Toronto Ontario M5G 2C4, Canada

I recently had the opportunity to read an issue of your journal while attending the 10th World Congress of the World Society of Cardio-thoracic Surgeons in Vancouver, BC, Canada (August 13–16, 2000). I would like to comment on the very interesting editorial on "Cardio-thoracic Surgery and Lessons from the Cockpit" by Clifford F Hughes from Sydney, Australia.¹ This article is extremely timely. In the United States and most other countries, there is increasing concern about medical errors and their effects on patient survival, morbidity, and mortality, and that between 44,000 and 98,000 patients die each year of preventable errors (in American hospitals). That this is greater than the deaths attributable to either motor vehicle accidents or breast cancer, is indeed astounding. If one extrapolates from this, the total deaths worldwide would indeed be staggering. In North America, these numbers have come to light from review of patient records, and may not necessarily reflect the actual incidence. Moreover, these numbers relate to patient deaths; the number of patients who have drug-related reactions, increased morbidity, and permanent residual damage must be significantly higher.

The reasoning of the author is unassailable that as a physician one must not only "above all, do no harm," one must also implement quality assurance programs.¹ The fact is: if we do not, someone else ultimately will. For a long time, we as a profession have had a monopoly — we regulated ourselves. Increasingly, hospital administra-tions, professional regulatory agencies, and our patients (through their "protectors": the lawyers) are beginning to ask more and more searching questions. They are less willing to take our word alone for an answer. The con-sequence of this has been the rapidly increasing number of medical law suits and large settlements related to physician errors.

I believe that a major deficiency in this editorial pertains to that age-old method of learning: the autopsy. The autopsy was the gold standard for quality of care and for learning (at times, from one's mistakes). The autopsy seems to have seen its best days. However, in spite of the fact that numbers are falling, in institutions where well-performed autopsies are undertaken by qualified and interested professionals, the information obtained is significant. Autopsies have great potential benefits for all concerned. For the family, they can show that the individual who died suddenly after a major procedure, in fact died of a natural cause, not exaggerated by the interventional procedure or surgery; there was no misadventure. On the other hand, the autopsy may show that the patient's death might have been preventable and might have been related to the procedure. This would provide an excellent learning experience for the clinical staff to improve their skills or change a technique, and perhaps provide material for publication.

For the surgeon or the treating team, the autopsy can (and often does) show that the procedure was performed well, however, there were ancillary lesions not diagnosed at the time of the investigations, which played a significant role in the outcome. Coexisting coronary artery disease not picked up on angiography, or coronary disease present in a relatively young individual and therefore not anticipated, are good and not uncommon examples. In both instances, the increased morbidity or mortality may have been related to the consequences of coronary artery disease. In a patient with significant preexisting myocardial damage, the autopsy may show that the procedure was indeed performed well with no factors that need to be altered, and that death was likely to have been related to the poor cardiac function associated with preexisting myocardial damage. Often enough, investigations show a grade-1-to-2 left ventricle, but by the time the patient comes to operation, the cardiac surgeon finds a grade-3 ventricle. The autopsy could offer some clues to the myocardial status.

In cases where the autopsy suggests changes in some aspects of the surgical procedure, the educational value of the autopsy to the clinical staff would be phenomenal. The visual material provided by the pathologist who did the autopsy, which can be demonstrated to the treating staff, makes an unbeatable learning experience. This experience should help to prevent recurrence of the problem. Series of such cases provide excellent teaching material for medical students and hospital staff, as well as data for publication.

Obviously, it is critical to have a well equipped and staffed pathology department. The pathology department and the pathologist are integral parts of the clinical team. It is wise and appropriate to make use of the full team and to apply the results obtained from the "final consultation". In the words of the late Sir William Osler: "As is your pathology, so is your medicine." Even in these days of positron emission tomography, computed tomography, and magnetic resonance imaging, the autopsy remains the gold standard for assuring quality of care in a proportion of cases.

Reference

1. Hughes CF. Cardiothoracic surgery and lessons from the cockpit. Asian Cardiovasc Thorac Ann 2000;8:96–7.

Cardiothoracic Surgical Unit Royal Prince Alfred Hospital 304/100 Carillon Avenue Newtown, Sydney, Nsw, Australia

Dr. Butany has raised a particularly pertinent point in the debate on quality programs. In Australian teaching hospitals, the autopsy rate has plummeted to an all time low. In non-teaching institutions, autopsies are usually only performed when required by law.

To our great distress, we have also become aware of circumstances in which coroners have declined requests from surgeons to perform autopsies, citing resource issues, administrative problems, etc., as reasons for their decision. Whilst one understands the occasional religious objection to autopsy and the inevitable distress that an autopsy may produce when funeral arrangements are delayed, the potential benefits are important and have been well outlined by Dr. Butany.

A sympathetic, compassionate approach to families in times of distress usually allows one to seek an autopsy in the majority of patients. I would strongly support better postmortem attention to our premortem activities.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Clifford F Hughes Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Butany, J. W Articles by Hughes, C. F Search for Related Content PubMed Articles by Butany, J. W Articles by Hughes, C. F