What is a Mortality Committee for? Autopsy as a quality indicator.

BACKGROUND: Clinical autopsy has played a central role in medical education, research, and quality assurance. Despite major advances in diagnostic technologies, clinically relevant discrepancies between premortem diagnoses and postmortem findings persist. However, declining autopsy rates have raised concerns about the loss of this tool as a marker of diagnostic accuracy and patient safety. Hospital Mortality Review Committees may help to integrate autopsy findings into quality improvement processes, although their real impact on clinical practice remains uncertain. We evaluate the contribution of clinical autopsies to the detection of major diagnostic discrepancies and examine how Hospital Mortality Review Committees may facilitate autopsy-based quality assessment in a tertiary care hospital.

METHODS: A retrospective observational study of adult in-hospital deaths undergoing clinical autopsy over a 10-year period was conducted at a large tertiary hospital in Spain. Premortem clinical diagnoses were compared with postmortem findings using the modified Goldman classification. Major diagnostic discrepancies were analyzed overall and by clinical department.

RESULTS: Two hundred eighty-four clinical autopsies were analyzed. Major clinicopathological discrepancies were identified in 30.3% of cases. The most frequent missed diagnoses were malignancies, pneumonias, invasive fungal infections, aortic dissections, pulmonary embolism, and acute pancreatitis. Major discrepancies were most commonly observed in patients from the intensive care unit and internal medicine services. In 12.7% of cases, autopsy did not identify a definitive cause of death, particularly among critically ill and multimorbid patients.

CONCLUSION: Major clinicopathological discrepancies (Goldman classes I-II) were identified in approximately one-third of autopsies, most commonly involving malignancies, infections, and cardiovascular diseases. Incorporation of autopsy findings allowed the identification of more clinically relevant diagnostic discrepancies than the initial clinical review alone. In this context, Hospital Mortality Review Committees may contribute to the systematic review of deaths and to the identification of potential areas for diagnostic and healthcare improvement. However, the low autopsy rate and the absence of structured feedback mechanisms may limit the translation of these findings into improvements in clinical practice and quality-of-care processes.