- Email: [email protected]
Common errors in writing the cause of death certificate in the Middle East
Journal of Forensic and Legal Medicine 68 (2019) 101864
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm
Review
Common errors in writing the cause of death certificate in the Middle East a,∗
b
b
b
Mohammed Madadin , Aishah S. Alhumam , Naimah A. Bushulaybi , Assayl R. Alotaibi , Hala A. Aldakhilb, Arwa Y. Alghamdib, Norah K. Al-Abdulwahabb, Shahad Y. Assirib, Nesreen A. Alumairb, Fai A. Almulhimb, Ritesh G. Menezesa a b
T
Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
ARTICLE INFO
ABSTRACT
Keywords: Death certificate Cause of death certification Middle East
A death certificate is an official document in which the medical practitioner primarily records the cause of death sequence, the time interval between the onset of the cause of death and death, and personal details of the deceased. Errors in death certificate documentation are not uncommon. We aim to review the common errors in writing the cause of death certificate in the Middle East. For this review, we searched the PubMed database using a comprehensive search strategy to identify studies from the Middle East that reported errors in the cause of death certification from inception to August 17, 2019. Of the 308 items initially identified, 5 were eligible for inclusion. These studies were reported from only a few countries (Saudi Arabia, Iran, Lebanon and Palestine) in the Middle East and did not represent all the countries geographically located in the Middle East. The Middle East is not immune to errors in the medical certification of the cause of death. The absence of the cause of death, inappropriate listing and sequencing of the causes of death, mentioning the mechanism or mode of death instead of the cause of death, absence of time interval between the onset of the cause of death and death, use of abbreviations and symbols instead of formal medical terminology, and absence of the certifying medical practitioner's signature were the commonly death certification errors observed in this regional literature review. Additional studies to assess death certification errors in all the Middle East countries are needed. Efforts should be made to compulsorily include the teaching and learning of the cause of death certification in the undergraduate medical curriculum. Interactive workshops on drafting the cause of death certificate should be periodically conducted for the benefit of the interns and residents.
1. Introduction A death certificate is an official document furnished by the medical practitioner where the cause of death sequence, the time interval between the onset of the cause of death and death, and personal details of the deceased are primarily recorded. The international form of medical certificate of the cause of death recommended by the World Health Organization (WHO) is being used worldwide to document the sequence of events leading to death.1 This form consists of the direct cause of death (immediate and antecedent causes of death) and other significant conditions contributing to death but not related to the direct cause of death.2 Such death certificates are often the data sources consulted for mortality statistics. The cause of death certificate is regarded as an essential source of mortality information, and is legally required for many court proceedings, such as in undertaking legal action (inheritance of property,
∗
insurance claims) and public health epidemiology.3 It is a legal proof of occurrence of death. Any errors in the information reported in death certificates may even result in the failure of prospective health policies. The major errors include missing underlying cause of death, competing potential underlying causes of death, and improper sequencing of the causes of death. Minor errors include improper use of abbreviations, mention of the mode or mechanism of death, and ignoring the time interval between the onset of the cause of death and death. Such errors relate to the poor quality of death certificates. Despite the development of guidelines on medical certification of the cause of death by the WHO,1 errors in death certificate documentation are not uncommon and are reported from different countries across the globe.4–6 Herein, we aim to review the common errors in writing the cause of death certificate in the Middle East.
Corresponding author. E-mail address: [email protected] (M. Madadin).
https://doi.org/10.1016/j.jflm.2019.101864 Received 10 June 2019; Received in revised form 18 August 2019; Accepted 26 August 2019 Available online 29 August 2019 1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
308
(death certificate OR cause of death certification OR death notification form OR death certificate errors OR writing the death certificate) AND (Middle East OR Bahrain OR Egypt OR Iran OR Iraq OR Israel OR Jordan OR Kuwait OR Lebanon OR Oman OR Palestine OR Qatar OR Saudi Arabia OR Syria OR Turkey OR United Arab Emirates OR Yemen)
((“death certificates”[MeSH Terms] OR (“death”[All Fields] AND “certificates”[All Fields]) OR “death certificates”[All Fields] OR (“death”[All Fields] AND “certificate”[All Fields]) OR “death certificate”[All Fields]) OR ((“cause of death”[MeSH Terms] OR (“cause”[All Fields] AND “death”[All Fields]) OR “cause of death”[All Fields]) AND (“certification”[MeSH Terms] OR “certification”[All Fields])) OR ((“death”[MeSH Terms] OR “death”[All Fields]) AND notification[All Fields] AND form[All Fields]) OR ((“death certificates”[MeSH Terms] OR (“death”[All Fields] AND “certificates”[All Fields]) OR “death certificates”[All Fields] OR (“death”[All Fields] AND “certificate”[All Fields]) OR “death certificate”[All Fields]) AND errors[All Fields]) OR ((“writing”[MeSH Terms] OR “writing”[All Fields]) AND (“death certificates”[MeSH Terms] OR (“death”[All Fields] AND “certificates”[All Fields]) OR “death certificates”[All Fields] OR (“death”[All Fields] AND “certificate”[All Fields]) OR “death certificate”[All Fields]))) AND ((“middle east”[MeSH Terms] OR (“middle”[All Fields] AND “east”[All Fields]) OR “middle east”[All Fields]) OR (“bahrain”[MeSH Terms] OR “bahrain”[All Fields]) OR (“egypt”[MeSH Terms] OR “egypt”[All Fields]) OR (“iran”[MeSH Terms] OR “iran”[All Fields]) OR (“iraq”[MeSH Terms] OR “iraq”[All Fields]) OR (“israel”[MeSH Terms] OR “israel”[All Fields]) OR (“jordan”[MeSH Terms] OR “jordan”[All Fields]) OR (“kuwait”[MeSH Terms] OR “kuwait”[All Fields]) OR (“lebanon”[MeSH Terms] OR “lebanon”[All Fields]) OR (“oman”[MeSH Terms] OR “oman”[All Fields]) OR Palestine[All Fields] OR (“qatar”[MeSH Terms] OR “qatar”[All Fields]) OR (“saudi arabia”[MeSH Terms] OR (“saudi”[All Fields] AND “arabia”[All Fields]) OR “saudi arabia”[All Fields]) OR (“syria”[MeSH Terms] OR “syria”[All Fields]) OR (“turkey”[MeSH Terms] OR “turkey”[All Fields]) OR (“united arab emirates”[MeSH Terms] OR (“united”[All Fields] AND “arab”[All Fields] AND “emirates”[All Fields]) OR “united arab emirates”[All Fields]) OR (“yemen”[MeSH Terms] OR “yemen”[All Fields]))
Search details
Search terms
Table 1 Search strategy to identify relevant literature.
5
Search results (number of items found)
Number of items that met the inclusion criteria
M. Madadin, et al.
Journal of Forensic and Legal Medicine 68 (2019) 101864
2
Journal of Forensic and Legal Medicine 68 (2019) 101864
3
BMC Research Notes Death Studies 2012 1997–2016 2017 2019
Palestine Saudi Arabia
Health Information Management 2010–2011 2014
Iran
2008 2012
Saudi Arabia
1974, 1984, 1994, 1997, 1998 2002
Origin of publication Year of issue of death certificates analyzed Year of publication
Table 2 List of articles that have reported death certificate errors in the Middle East.
Journal
Of the 308 items initially identified, 5 met the inclusion criteria. These studies were reported from only a few countries (2 from Saudi Arabia, 1 from Iran, 1 from Lebanon and 1 from Palestine) in the Middle East (Table 2).7–11 Four of these were published in international journals and 1 was published in a local journal. There were no studies included from the rest of the 12 countries geographically located in the Middle East. Two relevant articles originated from Saudi Arabia.8,11 The first was a cross-sectional study conducted at a university affiliated teaching hospital in Riyadh.8 Four hundred and twenty seven death certificates were evaluated for completeness. Of these, 17 death certificates had no data on the cause of death mentioned. Inappropriate causes of death were mentioned in 255 death certificates amounting to nearly 60% of the death certificates.8 The second Saudi study was also conducted at the same university affiliated teaching hospital (King Khalid University Hospital in Riyadh).11 One thousand six hundred and eighty eight death certificates were evaluated for any errors.11 Major errors like the absence of the cause of death or incorrect listing of the cause of death were noticed in 100% of the death certificates. In 70% of these death certificates, cardiopulmonary arrest was mentioned as the cause of death. Inappropriate terms like malignancy, renal failure, heart failure, liver failure, multi-organ failure, diabetes, and traffic accident were also observed in this study.11 The mention of traffic accident without providing details of the sequence of events leading to death merely suggests the manner of death rather than the cause of death. The mention of diabetes without stating a complication of diabetes mellitus leading to death does not provide clarity to the cause of death certification.11 A study conducted in a teaching hospital in Iran analyzed a total of 236 death certificates and identified missing or no acceptable underlying cause of death (8 certificates), competing potential underlying causes of death (28 certificates), and improper sequencing of the cause of death statement (74 certificates) as the major errors in death certification in 110 (47%) cases.9 The minor errors were identified in 168 (71%) death certificates and included repetitive phrases in different lines (15 certificates), illegible phrases (6 certificates), entry of mode of death (113 certificates).9 In 34 death certificates, both entry of repetitive phrases and mode of death were noted. Death certificates with
Bulletin of the World Health organization Annals of Saudi Medicine
Article
3. Results and discussion
Lebanon
The literature search strategy for the present review is depicted in Table 1. We ran a comprehensive search on the PubMed academic database on 17-August-2019 to identify studies that evaluated errors in writing the cause of death certificate reported from the Middle East using a combination of search terms and details as described in Table 1. The search strategy for PubMed comprised a combination of free text and MeSH (medical subject headings) terms. The search terms included “death certificate”, “cause of death certification”, “death notification form”, “death certificate errors” and “writing the death certificate”. In addition, to identify the related studies reported from the Middle East the search terms included “Middle East” and the countries geographically located in the Middle East, namely, “Bahrain”, “Egypt”, “Iran”, “Iraq”, “Israel”, “Jordan”, “Kuwait”, “Lebanon”, “Oman”, “Palestine”, “Qatar”, “Saudi Arabia”, “Syria”, “Turkey”, “United Arab Emirates” and “Yemen”. No language restrictions were placed on the search results. Screening of titles of the search results was followed by screening of abstracts and then retrieval and screening of the full-text. Studies from the Middle East that evaluated death certificate errors were included in the present review. Questionnaire based studies that assessed the medical practitioners’ knowledge and practice on death certification were not included in the present review. Studies that aimed to evaluate the validity of the causes of death stated in death certificates or reliability of death certificate diagnoses were also excluded from the present review.
Inadequacies of death certification in Beirut: Who is responsible? (Sibai et al.)7
2. Methods
Causes of death certification of adults: an exploratory cross-sectional study at a university hospital in Riyadh, Saudi Arabia. (Ansary et al.)8 Haghighi MH, Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. (Haghighi et al.)9 Quality of death notification forms in North West Bank/Palestine: a descriptive study. (Qaddumi et al.)10 Death certificate errors in one Saudi Arabian hospital. (Aljerian)11
M. Madadin, et al.
Journal of Forensic and Legal Medicine 68 (2019) 101864
M. Madadin, et al.
only minor errors, both minor and major errors, and only major errors were 37% (87 certificates), 34% (81 certificates), and 12% (29 certificates), respectively. Thirty nine death certificates (17%) were without any errors. Qaddumi et al. analyzed 547 death certificates furnished at the primary health care directorates in Palestine.10 In this study, two-third of the death certificates had at least one major error. The most common major errors were the absence of the underlying cause of death (44%) and incorrect sequence of causes of death (42%), followed by no acceptable cause of death (23%), and mention of competing causes of death (15%). Only 2% (12 certificates) of the death certificates were without any minor errors. Ninety eight percent (535 certificates) of the death certificates had at least one minor error. The most common minor errors were the absence of the time interval between the onset of the cause of death and death (97%) and the use of abrreviations and symbols (39%), followed by mention of irrelevant information (18%), and illegible writing (10%).10 Sibai et al. assessed the completeness of data on 2607 death certificates issued in Beirut, the capital of Lebanon, and the other districts.7 Important sociodemographic information about the deceased was almost complete in all the death certificates. The sex and month of death were missing in only 1.9% and 0.2% of death certificates, respectively. Fifty eight percent (1526 certificates) of the death certificates did not convey a cause of death. The certifying medical practitioner's signature was missing in 51% (1336 certificates) of the death certificates. Of those death certificates bearing the certifier's signature, 22% lacked the documentation of the cause of death. Of those death certificates without the certifier's signature, 94% lacked the documentation of the cause of death.7 In both the studies reported from Saudi Arabia, the absence of the cause of death and inappropriate listing of the cause of death were the most common major errors in death certification. Cardiopulmonary arrest was a common mechanism of death mentioned in Saudi Arabian death certificates. Improper sequence of the causes of death was the most common major death certification error in the Iranian study. The mention of the mode of death was another common error in the Iranian death certificates. Incorrect sequence of causes of death and absence of underlying cause of death were the most commonly recognized major errors and the absence of the time interval between the onset of the cause of death and death was the most commonly recognized minor error in the study reported from Palestine. The Palestinian study also reflected a tendency to use abbreviations and symbols instead of the formal medical terminology. In the Lebanese study, over one-half of the death certificates did not convey a cause of death and did not bear the certifying medical practitioner's signature.
major and minor errors related to mortality-related data were significant in a considerable proportion of death certificates. As significant consequences of inappropriate medical certificate of the cause of death include the conglomeration of poor data to formulate effective public health policies, identify disease trends, and support justice outcomes, serious efforts should be made to continuously educate medical practitioners. The deficiencies in the form of major and minor errors in death certification are corrigible. Efforts should be made to compulsorily include the teaching and learning of the cause of death certification in the undergraduate medical curriculum. Interactive workshops on drafting the cause of death certificate should be periodically conducted for the benefit of the interns and residents. There is a lack of studies assessing death certification errors in all the Middle East countries and therefore additional such studies should be steered. Funding Nil. Conflicts of interest None. Acknowledgment None. References 1. World Health Organization. Medical Certification of Cause of Death: Instructions for Physicians on Use of International Form of Medical Certificate of Cause of Death. Geneva: World Health Organization; 1979. 2. Centers for Disease Control and Prevention. Physicians' Handbook on Medical Certification of Death. Hyattsville: Centers for Disease Control and Prevention; 2003. 3. Leslie M. I can't put that on paper": how medical professional values shape the content of death certificates. Int J Law Context. 2016;12:178–194. 4. Katsakiori PF, Panagiotopoulou EC, Sakellaropoulos GC, Papazafiropoulou A, Kardara M. Errors in death certificates in a rural area of Greece. Rural Remote Health. 2007;7:822. 5. Maharjan L, Shah A, Shrestha KB, Shrestha G. Errors in cause-of-death statement on death certificates in intensive care unit of Kathmandu, Nepal. BMC Health Serv Res. 2015;15:507. 6. Pritt BS, Hardin NJ, Richmond JA, Shapiro SL. Death certification errors at an academic institution. Arch Pathol Lab Med. 2005;129:1476–1479. 7. Sibai AM, Nuwayhid I, Beydoun M, Chaaya M. Inadequacies of death certification in Beirut: who is responsible? Bull World Health Organ. 2002;80:555–561. 8. Ansary LA, Esmaeil SA, Adi YA. Causes of death certification of adults: an exploratory cross-sectional study at a university hospital in Riyadh, Saudi Arabia. Ann Saudi Med. 2012;32:615–622. 9. Haghighi MH, Dehghani M, Teshnizi SH, Mahmoodi H. Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. Health Inf Manag. 2014;43:35–42. 10. Qaddumi JA, Nazzal Z, Yacoup AR, Mansour M. Quality of death notification forms in North West Bank/Palestine: a descriptive study. BMC Res Notes. 2017;10:154. 11. Aljerian K. Death certificate errors in one Saudi Arabian hospital. Death Stud. 2019;43:311–315.
4. Conclusions and recommendations The Middle East is not immune to errors in the medical certification of the cause of death. Although only a negligible proportion of death certificates lacked important sociodemographic data of the deceased,
4
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm
Review
Common errors in writing the cause of death certificate in the Middle East a,∗
b
b
b
Mohammed Madadin , Aishah S. Alhumam , Naimah A. Bushulaybi , Assayl R. Alotaibi , Hala A. Aldakhilb, Arwa Y. Alghamdib, Norah K. Al-Abdulwahabb, Shahad Y. Assirib, Nesreen A. Alumairb, Fai A. Almulhimb, Ritesh G. Menezesa a b
T
Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
ARTICLE INFO
ABSTRACT
Keywords: Death certificate Cause of death certification Middle East
A death certificate is an official document in which the medical practitioner primarily records the cause of death sequence, the time interval between the onset of the cause of death and death, and personal details of the deceased. Errors in death certificate documentation are not uncommon. We aim to review the common errors in writing the cause of death certificate in the Middle East. For this review, we searched the PubMed database using a comprehensive search strategy to identify studies from the Middle East that reported errors in the cause of death certification from inception to August 17, 2019. Of the 308 items initially identified, 5 were eligible for inclusion. These studies were reported from only a few countries (Saudi Arabia, Iran, Lebanon and Palestine) in the Middle East and did not represent all the countries geographically located in the Middle East. The Middle East is not immune to errors in the medical certification of the cause of death. The absence of the cause of death, inappropriate listing and sequencing of the causes of death, mentioning the mechanism or mode of death instead of the cause of death, absence of time interval between the onset of the cause of death and death, use of abbreviations and symbols instead of formal medical terminology, and absence of the certifying medical practitioner's signature were the commonly death certification errors observed in this regional literature review. Additional studies to assess death certification errors in all the Middle East countries are needed. Efforts should be made to compulsorily include the teaching and learning of the cause of death certification in the undergraduate medical curriculum. Interactive workshops on drafting the cause of death certificate should be periodically conducted for the benefit of the interns and residents.
1. Introduction A death certificate is an official document furnished by the medical practitioner where the cause of death sequence, the time interval between the onset of the cause of death and death, and personal details of the deceased are primarily recorded. The international form of medical certificate of the cause of death recommended by the World Health Organization (WHO) is being used worldwide to document the sequence of events leading to death.1 This form consists of the direct cause of death (immediate and antecedent causes of death) and other significant conditions contributing to death but not related to the direct cause of death.2 Such death certificates are often the data sources consulted for mortality statistics. The cause of death certificate is regarded as an essential source of mortality information, and is legally required for many court proceedings, such as in undertaking legal action (inheritance of property,
∗
insurance claims) and public health epidemiology.3 It is a legal proof of occurrence of death. Any errors in the information reported in death certificates may even result in the failure of prospective health policies. The major errors include missing underlying cause of death, competing potential underlying causes of death, and improper sequencing of the causes of death. Minor errors include improper use of abbreviations, mention of the mode or mechanism of death, and ignoring the time interval between the onset of the cause of death and death. Such errors relate to the poor quality of death certificates. Despite the development of guidelines on medical certification of the cause of death by the WHO,1 errors in death certificate documentation are not uncommon and are reported from different countries across the globe.4–6 Herein, we aim to review the common errors in writing the cause of death certificate in the Middle East.
Corresponding author. E-mail address: [email protected] (M. Madadin).
https://doi.org/10.1016/j.jflm.2019.101864 Received 10 June 2019; Received in revised form 18 August 2019; Accepted 26 August 2019 Available online 29 August 2019 1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
308
(death certificate OR cause of death certification OR death notification form OR death certificate errors OR writing the death certificate) AND (Middle East OR Bahrain OR Egypt OR Iran OR Iraq OR Israel OR Jordan OR Kuwait OR Lebanon OR Oman OR Palestine OR Qatar OR Saudi Arabia OR Syria OR Turkey OR United Arab Emirates OR Yemen)
((“death certificates”[MeSH Terms] OR (“death”[All Fields] AND “certificates”[All Fields]) OR “death certificates”[All Fields] OR (“death”[All Fields] AND “certificate”[All Fields]) OR “death certificate”[All Fields]) OR ((“cause of death”[MeSH Terms] OR (“cause”[All Fields] AND “death”[All Fields]) OR “cause of death”[All Fields]) AND (“certification”[MeSH Terms] OR “certification”[All Fields])) OR ((“death”[MeSH Terms] OR “death”[All Fields]) AND notification[All Fields] AND form[All Fields]) OR ((“death certificates”[MeSH Terms] OR (“death”[All Fields] AND “certificates”[All Fields]) OR “death certificates”[All Fields] OR (“death”[All Fields] AND “certificate”[All Fields]) OR “death certificate”[All Fields]) AND errors[All Fields]) OR ((“writing”[MeSH Terms] OR “writing”[All Fields]) AND (“death certificates”[MeSH Terms] OR (“death”[All Fields] AND “certificates”[All Fields]) OR “death certificates”[All Fields] OR (“death”[All Fields] AND “certificate”[All Fields]) OR “death certificate”[All Fields]))) AND ((“middle east”[MeSH Terms] OR (“middle”[All Fields] AND “east”[All Fields]) OR “middle east”[All Fields]) OR (“bahrain”[MeSH Terms] OR “bahrain”[All Fields]) OR (“egypt”[MeSH Terms] OR “egypt”[All Fields]) OR (“iran”[MeSH Terms] OR “iran”[All Fields]) OR (“iraq”[MeSH Terms] OR “iraq”[All Fields]) OR (“israel”[MeSH Terms] OR “israel”[All Fields]) OR (“jordan”[MeSH Terms] OR “jordan”[All Fields]) OR (“kuwait”[MeSH Terms] OR “kuwait”[All Fields]) OR (“lebanon”[MeSH Terms] OR “lebanon”[All Fields]) OR (“oman”[MeSH Terms] OR “oman”[All Fields]) OR Palestine[All Fields] OR (“qatar”[MeSH Terms] OR “qatar”[All Fields]) OR (“saudi arabia”[MeSH Terms] OR (“saudi”[All Fields] AND “arabia”[All Fields]) OR “saudi arabia”[All Fields]) OR (“syria”[MeSH Terms] OR “syria”[All Fields]) OR (“turkey”[MeSH Terms] OR “turkey”[All Fields]) OR (“united arab emirates”[MeSH Terms] OR (“united”[All Fields] AND “arab”[All Fields] AND “emirates”[All Fields]) OR “united arab emirates”[All Fields]) OR (“yemen”[MeSH Terms] OR “yemen”[All Fields]))
Search details
Search terms
Table 1 Search strategy to identify relevant literature.
5
Search results (number of items found)
Number of items that met the inclusion criteria
M. Madadin, et al.
Journal of Forensic and Legal Medicine 68 (2019) 101864
2
Journal of Forensic and Legal Medicine 68 (2019) 101864
3
BMC Research Notes Death Studies 2012 1997–2016 2017 2019
Palestine Saudi Arabia
Health Information Management 2010–2011 2014
Iran
2008 2012
Saudi Arabia
1974, 1984, 1994, 1997, 1998 2002
Origin of publication Year of issue of death certificates analyzed Year of publication
Table 2 List of articles that have reported death certificate errors in the Middle East.
Journal
Of the 308 items initially identified, 5 met the inclusion criteria. These studies were reported from only a few countries (2 from Saudi Arabia, 1 from Iran, 1 from Lebanon and 1 from Palestine) in the Middle East (Table 2).7–11 Four of these were published in international journals and 1 was published in a local journal. There were no studies included from the rest of the 12 countries geographically located in the Middle East. Two relevant articles originated from Saudi Arabia.8,11 The first was a cross-sectional study conducted at a university affiliated teaching hospital in Riyadh.8 Four hundred and twenty seven death certificates were evaluated for completeness. Of these, 17 death certificates had no data on the cause of death mentioned. Inappropriate causes of death were mentioned in 255 death certificates amounting to nearly 60% of the death certificates.8 The second Saudi study was also conducted at the same university affiliated teaching hospital (King Khalid University Hospital in Riyadh).11 One thousand six hundred and eighty eight death certificates were evaluated for any errors.11 Major errors like the absence of the cause of death or incorrect listing of the cause of death were noticed in 100% of the death certificates. In 70% of these death certificates, cardiopulmonary arrest was mentioned as the cause of death. Inappropriate terms like malignancy, renal failure, heart failure, liver failure, multi-organ failure, diabetes, and traffic accident were also observed in this study.11 The mention of traffic accident without providing details of the sequence of events leading to death merely suggests the manner of death rather than the cause of death. The mention of diabetes without stating a complication of diabetes mellitus leading to death does not provide clarity to the cause of death certification.11 A study conducted in a teaching hospital in Iran analyzed a total of 236 death certificates and identified missing or no acceptable underlying cause of death (8 certificates), competing potential underlying causes of death (28 certificates), and improper sequencing of the cause of death statement (74 certificates) as the major errors in death certification in 110 (47%) cases.9 The minor errors were identified in 168 (71%) death certificates and included repetitive phrases in different lines (15 certificates), illegible phrases (6 certificates), entry of mode of death (113 certificates).9 In 34 death certificates, both entry of repetitive phrases and mode of death were noted. Death certificates with
Bulletin of the World Health organization Annals of Saudi Medicine
Article
3. Results and discussion
Lebanon
The literature search strategy for the present review is depicted in Table 1. We ran a comprehensive search on the PubMed academic database on 17-August-2019 to identify studies that evaluated errors in writing the cause of death certificate reported from the Middle East using a combination of search terms and details as described in Table 1. The search strategy for PubMed comprised a combination of free text and MeSH (medical subject headings) terms. The search terms included “death certificate”, “cause of death certification”, “death notification form”, “death certificate errors” and “writing the death certificate”. In addition, to identify the related studies reported from the Middle East the search terms included “Middle East” and the countries geographically located in the Middle East, namely, “Bahrain”, “Egypt”, “Iran”, “Iraq”, “Israel”, “Jordan”, “Kuwait”, “Lebanon”, “Oman”, “Palestine”, “Qatar”, “Saudi Arabia”, “Syria”, “Turkey”, “United Arab Emirates” and “Yemen”. No language restrictions were placed on the search results. Screening of titles of the search results was followed by screening of abstracts and then retrieval and screening of the full-text. Studies from the Middle East that evaluated death certificate errors were included in the present review. Questionnaire based studies that assessed the medical practitioners’ knowledge and practice on death certification were not included in the present review. Studies that aimed to evaluate the validity of the causes of death stated in death certificates or reliability of death certificate diagnoses were also excluded from the present review.
Inadequacies of death certification in Beirut: Who is responsible? (Sibai et al.)7
2. Methods
Causes of death certification of adults: an exploratory cross-sectional study at a university hospital in Riyadh, Saudi Arabia. (Ansary et al.)8 Haghighi MH, Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. (Haghighi et al.)9 Quality of death notification forms in North West Bank/Palestine: a descriptive study. (Qaddumi et al.)10 Death certificate errors in one Saudi Arabian hospital. (Aljerian)11
M. Madadin, et al.
Journal of Forensic and Legal Medicine 68 (2019) 101864
M. Madadin, et al.
only minor errors, both minor and major errors, and only major errors were 37% (87 certificates), 34% (81 certificates), and 12% (29 certificates), respectively. Thirty nine death certificates (17%) were without any errors. Qaddumi et al. analyzed 547 death certificates furnished at the primary health care directorates in Palestine.10 In this study, two-third of the death certificates had at least one major error. The most common major errors were the absence of the underlying cause of death (44%) and incorrect sequence of causes of death (42%), followed by no acceptable cause of death (23%), and mention of competing causes of death (15%). Only 2% (12 certificates) of the death certificates were without any minor errors. Ninety eight percent (535 certificates) of the death certificates had at least one minor error. The most common minor errors were the absence of the time interval between the onset of the cause of death and death (97%) and the use of abrreviations and symbols (39%), followed by mention of irrelevant information (18%), and illegible writing (10%).10 Sibai et al. assessed the completeness of data on 2607 death certificates issued in Beirut, the capital of Lebanon, and the other districts.7 Important sociodemographic information about the deceased was almost complete in all the death certificates. The sex and month of death were missing in only 1.9% and 0.2% of death certificates, respectively. Fifty eight percent (1526 certificates) of the death certificates did not convey a cause of death. The certifying medical practitioner's signature was missing in 51% (1336 certificates) of the death certificates. Of those death certificates bearing the certifier's signature, 22% lacked the documentation of the cause of death. Of those death certificates without the certifier's signature, 94% lacked the documentation of the cause of death.7 In both the studies reported from Saudi Arabia, the absence of the cause of death and inappropriate listing of the cause of death were the most common major errors in death certification. Cardiopulmonary arrest was a common mechanism of death mentioned in Saudi Arabian death certificates. Improper sequence of the causes of death was the most common major death certification error in the Iranian study. The mention of the mode of death was another common error in the Iranian death certificates. Incorrect sequence of causes of death and absence of underlying cause of death were the most commonly recognized major errors and the absence of the time interval between the onset of the cause of death and death was the most commonly recognized minor error in the study reported from Palestine. The Palestinian study also reflected a tendency to use abbreviations and symbols instead of the formal medical terminology. In the Lebanese study, over one-half of the death certificates did not convey a cause of death and did not bear the certifying medical practitioner's signature.
major and minor errors related to mortality-related data were significant in a considerable proportion of death certificates. As significant consequences of inappropriate medical certificate of the cause of death include the conglomeration of poor data to formulate effective public health policies, identify disease trends, and support justice outcomes, serious efforts should be made to continuously educate medical practitioners. The deficiencies in the form of major and minor errors in death certification are corrigible. Efforts should be made to compulsorily include the teaching and learning of the cause of death certification in the undergraduate medical curriculum. Interactive workshops on drafting the cause of death certificate should be periodically conducted for the benefit of the interns and residents. There is a lack of studies assessing death certification errors in all the Middle East countries and therefore additional such studies should be steered. Funding Nil. Conflicts of interest None. Acknowledgment None. References 1. World Health Organization. Medical Certification of Cause of Death: Instructions for Physicians on Use of International Form of Medical Certificate of Cause of Death. Geneva: World Health Organization; 1979. 2. Centers for Disease Control and Prevention. Physicians' Handbook on Medical Certification of Death. Hyattsville: Centers for Disease Control and Prevention; 2003. 3. Leslie M. I can't put that on paper": how medical professional values shape the content of death certificates. Int J Law Context. 2016;12:178–194. 4. Katsakiori PF, Panagiotopoulou EC, Sakellaropoulos GC, Papazafiropoulou A, Kardara M. Errors in death certificates in a rural area of Greece. Rural Remote Health. 2007;7:822. 5. Maharjan L, Shah A, Shrestha KB, Shrestha G. Errors in cause-of-death statement on death certificates in intensive care unit of Kathmandu, Nepal. BMC Health Serv Res. 2015;15:507. 6. Pritt BS, Hardin NJ, Richmond JA, Shapiro SL. Death certification errors at an academic institution. Arch Pathol Lab Med. 2005;129:1476–1479. 7. Sibai AM, Nuwayhid I, Beydoun M, Chaaya M. Inadequacies of death certification in Beirut: who is responsible? Bull World Health Organ. 2002;80:555–561. 8. Ansary LA, Esmaeil SA, Adi YA. Causes of death certification of adults: an exploratory cross-sectional study at a university hospital in Riyadh, Saudi Arabia. Ann Saudi Med. 2012;32:615–622. 9. Haghighi MH, Dehghani M, Teshnizi SH, Mahmoodi H. Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. Health Inf Manag. 2014;43:35–42. 10. Qaddumi JA, Nazzal Z, Yacoup AR, Mansour M. Quality of death notification forms in North West Bank/Palestine: a descriptive study. BMC Res Notes. 2017;10:154. 11. Aljerian K. Death certificate errors in one Saudi Arabian hospital. Death Stud. 2019;43:311–315.
4. Conclusions and recommendations The Middle East is not immune to errors in the medical certification of the cause of death. Although only a negligible proportion of death certificates lacked important sociodemographic data of the deceased,
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