J Korean Soc Clin Toxicol.  2020 Jun;18(1):11-17. 10.22537/jksct.2020.18.1.11.

Errors of Death Certificate for Poisoning Related Death

  • 1Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea


This study examines errors in death certificates (DCs) issued to cases of poisoning.
DCs issued in poisoning cases were retrospectively reviewed. Errors in the DC were classified as major and minor errors, and were evaluated in accordance with their impact on the process of selecting the cause of death (COD).
A total of 79 DCs were evaluated; 43 (54.4%) DCs were issued in the emergency department (ED), and 36 (45.6%) DCs were issued outside the ED. The average major and minor errors per DC were determined to be 0.4 and 3.3, respectively. Moreover, an average of 3.0 errors were discovered in DCs issued at the ED, and 4.4 errors in DCs issued outside the ED. The most common major errors were incorrect manner of death (11.4%, 9/79), followed by unacceptable COD (7.6%, 6/79), and the mode of dying as an underlying COD (5.1%, 4/79). The common minor errors most frequently encountered were incorrect time interval (86.1%, 68/79), followed by incorrect other significant conditions (73.4%, 58/79), and no record for date of onset (62.0%, 49/79).
Our results indicate that the total numbers of major errors, minor errors and cases of misjudged cause of death were greater in DCs issued outside the ED than in DCs issued at the ED. The most frequently quoted major error of DCs related to poisoning was determined to be the incorrect manner of death.


Death certificates; Cause of death; Poisoning
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