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Death Certificates May Not List an Accurate Cause of Death


Many death certificates fail to indicate that an individual died from healthcare-associated infections, which makes it difficult to identify dangerous medical trends

We go to the hospital when we are ill, and we expect to get better after the treatment, procedure, surgery or therapy that we receive there. We do not expect that we will become so ill that we die. But perhaps we should reset our expectations.

This is because while physicians and hospitals may help us to regain our health, there are thousands of incidents where individuals with non-life threatening medical conditions enter a hospital, only to never emerge or to leave, but soon die because of some illness they became infected with while in the care of the hospital.

One of the great public health and medical success stories of the 20th century was the development of antibiotics. The prevention of death by bacterial infections with antibiotics has saved millions of lives and made many medical procedures routine and unremarkable, when in prior eras they would have carried a high risk of infection and death.


In the last few years, that success has been undermined by the growing presence of what are sometimes called “superbugs.” These are bacteria that have become resistant to antibiotic after antibiotic until they are resistant to all. These infections are often identified by acronyms, such as CRE, CRKP, MRSA or abbreviations, like the aptly named C. difficile.

These bacteria have acquired antimicrobial resistance (AR) and because they are often found in hospitals, they cause what are known as healthcare-associated infections (HAI). One of the difficulties with this issue is we do not always know the full scope of the problem. A recent story in the Los Angeles Times noted that when a woman died after undergoing elective perforated ulcer, the cause listed on her death certificate was respiratory failure and septic shock caused by her ulcer, with no mention of the carbapenem-resistant Klebsiella pneumonia (CRKP) that caused the septic shock.

No reporting

The paper investigated and found that this was a common practice and that the state’s law did not require that a hospital report incidences of a hospital-acquired infection. Two dozen states do, but California lacked mandatory reporting requirements. When asked, one county employee told the deceased woman’s daughter that CRKP was not reportable, because “its everywhere.” This is less than reassuring.

It is impossible to deal with a health issue like this if no one knows the scope of the issue. If it really is “everywhere,” something should be done sooner rather than later. Diseases like CRKP can be spread by contact, which means any patient in a hospital where it is found is potentially at risk should a doctor or nurse attend to a infected patient and then touch anyone else without having properly washed their hands. The county stopped collecting data due to “resource issues,” likely meaning inadequate funding.

One case discussed by the Times article found that a 15-year-old boy died from a MRSA infection which according to his parents he apparently acquired during an MRI from a pad used in the machine. Again, his death certificate had no indication he died from an HAI.

The Centers for Disease Control and Prevention (CDC) estimates 75,000 patients die every year from HAIs, but one official from the CDC admits that the estimate may be a substantial undercount.

We don’t know what we are missing

By failing to maintain accurate records, underreporting can lead to hospital and other medical oversight bodies to not prioritize scrutiny of healthcare facilities for this issue. In one report from Massachusetts in 2011, found that almost half of all hospitals in the state had patients infected with CRE.

Earlier this year a report found potentially hundreds of patients were exposed to these deadly infections spread by the use of gastrointestinal scopes, or duodenoscope. These devices can pick up bacteria from infected patients and spread them to additional patients who are examined by the same scope if it is not properly disinfected. There were some concerns that the design of some of these scopes was such that cleaning may not actually produce a disinfected scope.

Consumers cannot judge the quality of hospital care if there is no way of knowing, beyond voluntary compliance, how patents die. Death certificates should provide a vehicle for tracking and discovering trends. When death certificates mask the true cause of death, the likelihood of that cause being discovered and minimized or eliminated, is significantly reduced.