Adverse event analysis in fatal cases of influenza A (H1N1) - a lesson from Poland.

During pandemic of influenza A (H1N1) in 2009 the relationship between mortality and medical errors, especially delayed antiviral treatment initiation, was highlighted in many studies. Our study was based on 5 fatal cases of pandemic influenza A (H1N1) hospitalized in Poland between November 2009 and February 2011. The material included data from medical documentation as well as testimonies from medical personnel and patients' families recorded during on-going lawsuits alleging medical malpractice. The risk factors of adverse events were: lack of typical symptoms, lack of detailed medical history, clinical masking of a "trivial" illness, doctors' ignorance and insufficient knowledge, several physicians treating the same patient during hospitalization. Recommendations for improving management of pandemic infectious disease include: an effective, quick and detailed system of information about the epidemiological threat, clear indication of units with diagnostic and medical possibilities, rational health policy and national system of closed claims and adverse event analysis.