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May 03, 2007
MICU misdiagnosis
One does not have to search far for examples of clinical iatrogenesis. But one must also be careful of accepting every report of misdiagnosis and error. A study published in Chest in 2001 looked at records of 1800 admissions to a MICU. Of the 401 patients that died, 91 had autopsies. Eighteen of those had a different diagnosis from that which was made clinically. Eight of those were considered major, with a direct impact on therapy. The other ten patients had an unexpected major finding, but would not have changed therapy. So is the conclusion that one in five ICU deaths are misdiagnosed? (18/91)
No. First, patients who underwent autopsy presumably were more confusing or sicker than those who didn't. So it is doubtful if the percentages can be extended to all the deaths.
Second, only 8/91 would have been helped by correct diagnosis. Or would they? The assumption is made that a correct diagnosis would have saved these patients. But looking at the situations with the eight, I doubt more than one or two could have been saved. Heart attacks, pneumonia, pulmonary embolism, peritonitis from perforated duodenal ulcer, infections after double lung transplant; these are very difficult to treat and frequently fatal even with appropriate treatment.
Also, are we to assume that autopsy findings are always the "real cause" of death. Isn't that an unprovable assumption, a philosophical decision, rather than a given?
Now to be fair, the purpose of the study was not to look at clinical iatrogenesis, but to prove the value of autopsy. The authors assert the value and then seek to support it.
Although this study may not be the best at demonstrating clinical iatrogenesis, it does exude the hubris that brought about the nemesis.
Clinical Iatrogenesis | By Robert Maddox | 10:23 PM