Death Certification: Errors and Interventions

Abstract

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.

Assessing state level variation in signature authority and cause of death accuracy, 2005–2017

“…Neglected in this report is the fact that physician extenders, most commonly physician assistants and advanced practice registered nurses, are increasingly responsible for medical certifications of death across the US ( American Association of Nurse Practitioners, 2018 , Ruiz et al, 2018 , McGivern et al, 2017 , Keepnews, 2010 ). Several studies suggest that some certifier characteristics may influence data validity and accuracy, and death certificate training, familiarity, and experience are salient to accurate cause of death reporting ( McGivern et al, 2017 , Lakkireddy et al, 2004 , Lloyd-Jones et al, 1998 , Messite and Stellman, 1996 , Pritt et al, 2005 , Schuppener et al, 2020 , Johnson et al, 2012 , McCaw-Binns et al, 2015 ). Only one of these studies ( McGivern et al, 2017 ) has assessed differences in death certificate completion accuracy by certifier type, inclusive of nurse practitioners; however, the study is geographically limited to the State of Vermont.…”

“…Only one of these studies ( McGivern et al, 2017 ) has assessed differences in death certificate completion accuracy by certifier type, inclusive of nurse practitioners; however, the study is geographically limited to the State of Vermont. The remaining studies have focused on solely one type of certifier ( Lakkireddy et al, 2004 ) or are geographically limited to one state ( Lloyd-Jones et al, 1998 , Messite and Stellman, 1996 , Pritt et al, 2005 , Schuppener et al, 2020 , Johnson et al, 2012 ). Research suggests that among professionals who certify cause of death statements on death certificates, medical examiners receive the most training in identifying causes of death and completing the death certificate ( Ruiz et al, 2018 , Timmermans, 2006 ).…”

“…Research suggests that among professionals who certify cause of death statements on death certificates, medical examiners receive the most training in identifying causes of death and completing the death certificate ( Ruiz et al, 2018 , Timmermans, 2006 ). Alternatively, physicians and other health care providers receive little or no formal training on death certification ( Messite and Stellman, 1996 , Schuppener et al, 2020 , Johnson et al, 2012 ), and training for coroners varies substantially throughout the US ( Ruiz et al, 2018 , Timmermans, 2006 , CDC, 2015 , Jentzen, 2009 , Hanzlick, 1996 , Hanzlick, 2006 ).…”

The impact of errors in medical certification on the accuracy of the underlying cause of death

“…completing the MCCOD) is strongly dependent on accurately recording the chain of morbid events leading to death in an acceptable sequence, legibly, and without use of nonstandard abbreviations, symptoms, modes of dying and other ill-defined causes that can make coding very difficult [ 2 , 3 ]. Despite the very clear rules of ICD-10, however, errors in death certification are common and have been noted worldwide [ 1 , 4 – 13 ]. The types of errors range from reporting multiple causes on a line of the MCCOD and using abbreviations, to the selection of ill-defined conditions for the UCOD [ 2 ].…”

Changes in Cause-of-Death Attribution During the Covid-19 Pandemic: Association with Hospital Quality Metrics and Implications for Future Research

“…31 Although we are not aware of studies linking QMs to CODA, it is known that CODA errors are more likely to occur in hospitals than elsewhere, 32 with an 85% error rate reported in comparisons of death certificates with autopsy findings at one regional academic institution. 33 The potential effect of financial incentives on CODA is particularly important for SARS-CoV-2 because several competing CODs, including chronic lower respiratory disease (CLRD), acute myocardial infarction, heart failure, pneumonia, and stroke, are included in Medicare 30-day mortality measures used to calculate prospective payment rates. 34 All but one of these (CLRD) is included in Agency for Healthcare Research and Quality inpatient quality indicators.…”