<- Home <- Arhive <- Vol. 31, Issue 2, June 2023

Rom J Leg Med31(2)126-132(2023)
© Romanian Society of Legal Medicine


M. A. Apostolović, A. Ignjatović, M. Stojanović, Z. Milošević, S. Stević, B. Apostolović, D. Krtinić, I. Stojanović,

Abstract: Although death certification belongs to obligatory physicians’ duties, many report uncertainties about the proper completion process. Medical death certificates (MDC) are of relatively low quality and not valuable for creating medical policy.
This research aims to determine the MDC frequency and error types and identify factors associated with their inaccuracies. A secondary goal was to investigate how frequently findings of medical autopsies influence the underlying cause of death (UCD).
Our research included a sample of 318 patients who died during hospitalization at the University Clinical Center Niš. Errors are divided into two categories: MAJOR and MINOR errors.
Two hundred and sixty four (83%) of all death certificates recorded errors that were significantly more common among the elderly deceased and MDCs requesting an autopsy. Autopsy findings caused the number of cancer diagnoses (C00-D99) to increase while garbage codes decreased significantly. The observed disagreement of 3-digit ICD-10 coded underlying condition after an autopsy was 57 (62.6%), while 23.1% of UCD resulted in an ICD category change. Our results signify a high rate of errors during death certification. The low quality of death certificates can be found in a lack of formal training and reduced health workers’ awareness about the importance of certification for health policies. A high percentage of ICD changes in disease categories indicate that autopsies remain an essential aid for mortality statistics.
Keywords: medical death certification, major errors, minor errors, autopsy, hospital settings.

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