Death Certification: Errors and Interventions

OBJECTIVE: Death certificates are legal documents containing critical information. Despite the importance of accurate certification, errors remain common. Estimates of error prevalence vary between studies, and error classification systems are often unclear. Relatively few studies have assessed the frequency at which death certification errors occur in US hospitals, and even fewer have attempted a standardized classification of errors based on their severity. In the current study, our objective was to evaluate the frequency of death certification errors at an academic center, implement a standardized method of categorizing error severity, and analyze sources of error to better identify ways to improve death certification accuracy. DESIGN: We retrospectively reviewed the accuracy of cause and manner of death certification at our regional academic institution for 179 cases in which autopsy was performed between 2013-2016. We compared non-pathologist physician completed death certificates with the cause and manner of death ultimately determined at autopsy. METHODS: Errors were classified via a 5-point scale of increasing error severity. Grades I-IIc were considered minor errors, while III-V were considered severe. Sources of error were analyzed. RESULTS: In the majority of cases (85%), death certificates contained ≥ one error, with multiple errors (51%) being more common than single (33%). The most frequent error type was Grade 1 (53%), followed by Grade III (30%), and Grade IIb (18%). The more severe Grade IV errors were seen in 23% of cases; no Grade V errors were found. No amendments were made to any death certificates following finalization of autopsy results during the study period. CONCLUSION: This study reaffirms the importance of autopsy and autopsy pathologists in ensuring accurate and complete death certification. It also suggests that death certification errors may be more frequent than previously reported. We propose a method by which death certification errors can be classified in terms of increasing severity. By understanding the types of errors occurring on death certificates, academic institutions can work to improve certification accuracy. Better clinician education, coordination with autopsy pathologists, and implementation of a systematic approach to ensuring concordance of death certificates with autopsy results is recommended.