REV.CHIM.(Bucharest)♦ 67♦ No. 8 ♦ 2016 http://www.revistadechimie.ro 1587

*email: gabriellostun@gmail.com; Tel.: +40740163109 # All authors have contributed equally to this paper

A Retrospective Study of Non-violent Deaths and DiagnosticDiscrepancies Over a Period of Three Years

ALEXANDRA LOSTUN1# , GABRIEL LOSTUN2*#, RAZVAN HAINAROSIE3,4#

1 University of Medicine and Pharmacy, Department of Forensic Medicine, 38 Gheorghe Marinescu Str., 540142,Tirgu Mures,Romania2University of Medicine and Pharmacy, Department of Human Anatomy, 38 Gheorghe Marinescu Str., 540142,Tirgu Mures,Romania3 Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474, Bucharest, Romania4 Prof. Dr. D. Hociota Institute of Phonoaudiology and Functional ENT Surgery, 2t Mihail Cioranu Str.,05075, Bucharest, Romania

Is there a relationship between non-violent deaths of in-hospital patients and diagnostic discrepancies, lackof medical guides or overestimated action of biocides used? The authors of this article want to find thedetailed implications of the above on the hope of survival of some categories of patients.Using statisticanalysis of medical data over a 3 years period, both from pathology and forensic registries we wanted toasses the quality of the medical act and the details of the non-violent deaths such as time of hospitalization,discrepancies, department where the death took place, final diagnostic. The results showed constant dataon all of the three years taken into study. Most deaths occurred in the ICU, coronary intensive care units,cardiac surgery department and emergency department. The most frequent missed diagnostic/discrepancyincluded bronchopneumonia and confusion between acute pulmonary and coronary conditions.As conclusionwe would like to raise an exclamation point as both the medical part by diagnostic discrepancies and theeconomical-management factors (low payment, lack of guides, counterfeited biocides, experience of themedical staff) influence the results the medical sector and the numbers do not have a tendency to lookbetter.

Keywords: diagnostic discrepancies, non-violent deaths, biocides, bronchopneumonia

One of the best ways for assessing the quality of amedical act is to try and find the discrepancy or correlationbetween two points of view coming from differentspecialties that have to deal with the same pathology. Thisis the case when the actions of a clinician or a surgeon arejudged indirectly by the autopsy report of a pathologist or aforensic medicine specialist.

Even though continuous research leads to day-by-dayadvancement in the quality of a medical procedure thediagnostic discrepancies are still at a high peak. TheGoldman’s criteria for assessing the missed diagnoses hasa four category standardization: two types of majordiscrepancies (related to missed cause of death that couldor could not have prolonged survival), and two minordiscordances (unrelated to cause of death that could haveaffect prognosis or have genetic or epidemiological value),concordant cases or non-classifiable cases; the remainingcases are considered even concordant or non-classifiable[1,2]. Over the passing of time the pattern showed a growthof the minor discrepancies and decrease of the major ones.

An important issue for the non-violent category of deathsseems to be correct evaluation of the acute cardio-pulmonary conditions for the emergency cases and thishappens even when a complete arsenal of diagnosticinstruments stand in the hands of the medical staff. In ourstudy we searched for the diagnostic discrepancies inhospitalized patients that underwent necropsy for non-violent deaths using firstly the Goldman’s classes but alsoour own criteria.

The research we conducted before starting our ownshowed us the directions of the last years. Worldwide theproblems seemed to have arisen in various areas:insufficient attention when diagnosed [5, 7, 10], not enoughcare when diagnostic where checked by forensic or

pathology specialist [6, 11], international guides andconsensus discrepancies [8, 9, 12-14], unknown orunrecognized in hospital infection [3]. All of the literaturecited by the authors showed that the best possibility toassess the problem is starting from its end by studying thework of pathologists and forensic specialists [4].

Experimental partMaterial and methods

The authors of the article chose a 3-year time interval(2009-2011) and selected the cases both from a forensicmedicine institution and a pathology department from acounty capital and renowned medical school in Romania.The forensic medicine department serves for 3 countiesand the pathology department belongs to one of the biggesthospitals by the number of beds in Romania. From a totalof 3032 autopsies 363 cases were picked.

There were 139 cases chosen from the forensicmedicine registries and the rest of 224 from the pathologydepartment of the county hospital. The percentage fromthe total was comparable so we decided to analyze thedata as a whole.

The inclusion criteria were minimum 24 hours ofhospitalization and non-violent death – any trauma orpolitrauma, found bodies or other kind of violent death wereexcluded.

We then made statistic analysis of the numbers obtainedusing the following criteria: sex, age (maximum,minimum, median), and class of discrepancy. We alsodivided the patients by the department were the death tookplace and we were also interested on the number of daysof hospitalization.

The next segregation criteria used was to find out dataabout the most common cause of non-violent death for

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the in-hospital patients – bronchopneumonia. These caseswere divided between individuals for who this conditionwas known and was the primary cause of death andindividuals for who this was found later during necropsy –discrepancy cases.

Probably the most important standardization was yetthe one of the discrepancy cases – we numbered herethese categories: nosologic, ethiologic, localization, finalcomplications, associated diseases and variouscombinations of them. (cf – final complications, nel –nosologic, ethiologic, localisation, ne – nosologic,ethiologic, l - localisation, necf – nosologic, ethiologic, finalcomplications, nlcf – nosologic, localization, finalcomplications, nelcf – nosologic, ethiologic, localization,final complications, elcf – ethiologic, localization, finalcomplications, ecf – ethiologic, final complications, n -ethiologic, ncf – nosologic, final complications, nel –nosologic, ethiologic, localisation, cf – final complicationswith associated disseases, cf fara bronho – finalcomplications without bronchopneumonia, e - ethiologic,boli associate – associated diseases).

The final type of analysis we applied to our group was tosplit them into three new categories that we have definedafter modification of the Goodman criteria fordiscrepancies. We chose to introduce the cases into thefirst category if the error could have saved the life of thepatient, the second if it might have prolonged its life andthird one if it could not influence the hope for living of theindividual.

Results and discussionsThe percentage of cases from the pathology department

was comparable with the one from the forensic medicineinstitution – 38.29 % forensic and 61.71 % pathology.

There were about 100 cases taken into study for eachyear.

The eldest patient was 99 years old and the youngestones one day. The median value was ranging from 55.7 to64 years in adults and from 6 months to 2 years and 27days in children.

The sex ratio was favorable to male patients during everyyear and also in general. 63.3% male was the percentagefor the forensic data and a median range of over 60% ingeneral. Under the age of 18 we have found a variationfrom 23.75% up to 44.11%.

The minimal hospitalization time was according to ourinclusion criteria one day and the maximum rose up to fivemonths. The median value was fluctuating from 8.98 daysto 10.6 days.

As it regards the place where the death took place thefirst 4 places are occupied as it follows: 137 deaths in ICU(43.91%), 45 (14.42%) in SMURD (mobile service for

emergencies), 41 (13.14%) in cardio-vascular surgery unitand its own ICU unit and 13 (4.16%) in Children ICU (fig. 1).The rest of the cases were divided among variousspecialties such as E.N.T., internal medicine, surgery,psychiatr y, gynecology, neurology, plastic surgery,pneumology, infectious diseases, cardiology, pediatric,orthopedics, neurosurgery, gastroenterology, diabetes andnumbered each less than 10 cases per category.

In the group with known bronchopneumonia diagnosisthere were 55 out 73 in 2009, 33 out of 34 in 2010 withdiscrepancies, 37 out of 39 in 2011.

For the part of novelty our new 3 classes of diagnosticdiscrepancies were divided as this: 246 cases in the firstclass, 74 cases in the second class and 42 in the third (fig.2).

In the category of diagnostic discrepancy cases we havefound that the data was similar for the years of the study.The statistic for 2009 included 40 cases with finalcomplications discrepancy (28.77%) and 36 cases withnosologic-ethiologic-localization-final complicationdiscrepancy (25.89%). For 2010 the final complicationswere found in 29 cases (27.61%), lethal final complicationsin 20 cases (19.04%) and nosologic-ethiologic-localization-final complication discrepancy in 10 cases (9.52%). For2011 final complications were in 22 cases (18.48%), lethalfinal complications in 32 cases (26.89%) and nosologic-ethiologic-localization-final complication discrepancy in 27cases (22.68%)(fig. 3). The rest of the types of diagnosticdiscrepancies were not included in tables/charts as theynumbered less than 10 cases each and we consideredthem with less influence to our study.

The work of the authors above can be considered ofhighly importance as nowadays medicine is more and morebased on evidence and statistic data that shows itsevolution and future direction. We consider in orderachieving as good as possible results anyone should beprepared to look back at their mistakes no matter if theywere with or without intention.

Starting from the base principle of medicine Primo NonNocere we believe the results of our study should be awarning sign for the Romanian medicine.

The data obtained shows unfortunately that the mostcommon place of non-violent deaths is the intensive careunits, general emergency services and cardiovascularsurgery unit along with its own ICU unit. This raises a bigquestion mark as the study was conducted in a traditionaluniversity center of the country renowned for the birth ofS.M.U.R.D. emergency service that now exists in everycounty and also for the cardiac surgery institute were evenheart transplant surgery is performed.

The problem for the ICU and emergency departmentshows to have been the bronchopneumonia missed

Fig.1. Most frequent places where in hospital non-violentdeaths took place

Fig.2. Newly proposed classes of discrepancies

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diagnosis, which in many cases proved to be fatal, and thepoor differential diagnosis between acute pulmonary andcardiac conditions.

The bronchopneumonia as cause of death in ICU couldbe considered a sign of something even more dangerous –the high possibility of nosocomial infection and the lack ofcare from the medical staff.

The affirmation above is sustained by the authors withexact data of cases showing patients that died from lethalfinal complications of totally other condition than the oneadmitted with (undiscovered tumors, metastasis). Theacute cardiac or pulmonary conditions need specialassistance but in ICU this should be applied for every patientand the fact that patients die from sepsis with primarylocalization bedsores, aspiration bronchopneumonia istotally unacceptable as this should be the place to saveand care for life. The resources in ICU are complete andtherefor the results expected should be fulfilled.

ConclusionsOur study shows the background of the nowadays-main

problems in the Romanian medical system.Underfinancing leads to insufficient medical staff,

corruption, poor care for the patient and increase numberof non-violent deaths.

The high number of bronchopneumonia cases especiallywith nosocomial germs shows that inefficient biocides areused.

Quite often confusion between heart attack and acutepulmonary embolism could tell something aboutinsufficient technical solutions but as we speak about acounty emergency hospital this is excluded and thehypothesis of insufficient training and experience of themedical staff comes first.

It seems that the ICU and SMURD emergency serviceare the first hit of the medical staff hemorrhage of the lastyears and probably faults may appear also because of theworking conditions meaning double shifts and high stress.

Much better qualified and experienced medical staff andless use of volunteers in the emergency services couldmodify this statistic. The doctors could not distinguish thefinal complications (lethal or non-lethal) in a high numberof cases.

The authors want to stress once again the necessity formedical and surgical guides that in Romania almost donot exist. Even if the Intensive care and AnesthesiologyRomanian Society has guidelines officially unfortunatelythe study shows that the highest incidence is right in thisplace.

There could be a problem with application of certainrules as the nurses and other medical staffs that directlytake care of the patient and its hygiene are insufficientlytrained and due to poor payment are not motivated.

As a final conclusion we state that if the workingconditions of the medical staff do not improve not only bymaterial earnings but especially from the point of view ofthe medical financing in general and better doctor perpatient ratio combined with high level of training the resultsthis study shows could worsen even more in a couple ofyears. The problem is just as serious even if we see it fromthe point of economic-management factors - lowpayment, lack of guides, counterfeited biocides,experience of the medical staff or from the strictly medicalpoint of view – diagnostics discrepancies, misseddiagnostic etcetera.

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Fig.3. Diagnostic discrepancies byyears – the graphic shows a

decrease of final complications andnosologic-ethiologic-localization-final

complications categories but anincrease of lethal final complications

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Manuscript received: 14.03.2016