NCJ Number
141736
Journal
Journal of Forensic Sciences Volume: 38 Issue: 2 Dated: (March 1993) Pages: 327-338
Date Published
1993
Length
12 pages
Annotation
The coroner's files and related hospital records were used to evaluate the circumstances surrounding the detection of fatal therapeutic misadventures and the adequacy of notification by care providers in Allegheny County, Pennsylvania. The reporting period spanned January 1982 through December 1991.
Abstract
The total number of cases identified as therapeutic misadventures was 63 for the reporting period; the annual average rate was 2.2 per 100,000 hospital admissions or 4.7 per million inhabitants. In 60 percent of the cases, the victim died within 24 hours from occurrence of the misadventure. The fatal misadventure rate at university- related hospitals was 118.2 per 100,000 beds per year, double the rate at community-based hospitals (53.9 per 100,000 beds per year). In more than half the cases, the hospital reported the incident within the hour, in 28.6 percent of the cases within 5 hours, and in 19 percent of the cases after more than 5 hours. The results showed that the hospital notification was deficient in 10 cases. In several instances, the death was initially reported by family members, hospital pathologists, or the media. To correct the underreporting of these misadventures to the medicolegal system, the Allegheny County Coroner's Office has proposed legislation that would mandate prompt reporting of therapeutic misadventures in the patient's medical records, to the State Boards of Health and Medicine, and to the coroner's office. The State Board of Health would be required to notify biannually health care providers of the number, types, and circumstances of such incidents. 8 tables and 20 references