4. November 2024

En nasjonal strategi for obduksjoner mangler. Fra: Tidsskriftet Den norske legeforening

 

 https://tidsskriftet.no/2022/05/debatt/en-nasjonal-strategi-obduksjoner-mangler

Dagens tilfeldige rekvisisjonspraksis og lave obduksjonstall tyder på at lovverket rundt kvalitetssikring av helsevesenet ikke etterfølges.

Forskrift om ledelse og kvalitetsforbedring i helse- og omsorgstjenesten omtaler plikten til å evaluere uønskede hendelser (1). Helsedirektoratet nevner ulike evalueringsmetoder, men vier ikke helsetjenestens viktigste kvalitetssikringsmetode ved død, den medisinske obduksjonen, ett ord (2).

Medisinske framskritt er ingen garanti for korrekt diagnose og behandling, og lave obduksjonsrater kan dessuten medføre en overestimering av diagnostisk treffsikkerhet (3). En litteraturstudie fra 2003 viste at diagnostiske feil var korrelert til obduksjonsfrekvens, også etter korreksjon for synkende obduksjonstall (4). Ved en obduksjonsrate på 5 % ville man forvente alvorlige feildiagnoser i 24 % av obduksjonene. Feilratene har ikke endret seg vesentlig de siste tiårene (5).

Medisinske feil er et helseproblem

Det hevdes at 2–4 % av dødsfallene i USA skyldes medisinske feil (6). Dødelige feil i norske sykehus anslås i en studie å forekomme i 0,3 % av alle sykehusinnleggelser (7). Tallene er beheftet med usikkerhet, men det er enighet om at medisinske feil utgjør et helseproblem (8).

Helsemyndighetene må nå på banen og klargjøre obduksjonstjenestenes rolle

Helsetilsynsloven og spesialisthelsetjenesteloven pålegger å varsle om dødsfall som kan skyldes medisinske feil eller uhell (9, 10). En stor andel rapporteres ikke, og problemet er internasjonalt (11, 12). At det er mangelfull etterfølgelse av lovverket, er intet nytt, men meldekulturen kan forbedres med enkle midler (13).

Medisinske obduksjoner utføres i dag sporadisk og tilfeldig og i et antall som er for lavt til å være av betydning for helsevesen, forskning eller statistikk. Synkende obduksjonsandeler vakte bekymring, og en ny obduksjonslov fra 2016 stadfestet derfor at leger har plikt til å vurdere obduksjon ved alle dødsfall, med kostnader dekket av det offentlige (14, 15). Loven framstår med en intensjon om at obduksjoner aktivt skal benyttes i kvalitetssikring av medisinsk virksomhet.

Obduksjonsloven er ikke gjort allment kjent, og ingen kontrollerer om den blir etterfulgt

Problemet er imidlertid at obduksjonsloven ikke er gjort allment kjent, og ingen kontrollerer om den blir etterfulgt. Helsemyndighetene må nå på banen og klargjøre obduksjonstjenestenes rolle.

Hva er nødvendig?

Det er flere tiltak som må til for at obduksjonstjenesten skal kunne fylle sin tiltenkte rolle. Obduksjonsandelen må gjøres til en kvalitetsindikator i helsetjenesten (16). Kvalitetsavdelingene må samarbeide med obduksjonspatologene, som må integreres i det kliniske kvalitetsarbeidet.

Nasjonale retningslinjer for utvelgelse til obduksjon og gjennomføring må på plass. Den europeiske og den norske patologforeningen har publisert standarder, disse må løftes og gjøres forpliktende (17, 18).

Den medisinske obduksjonspatologien må dessuten styrkes faglig. Subspesialisering må vurderes og ses i sammenheng med organisering og faglig styrking også av de rettsmedisinske obduksjonstjenestene (19, 20).

Obduksjonstjenestene må kvalitetssikres, både med hensyn til gjennomføring og rapportering. Lange svartider er et av flere problem som må løses (21). Et sentralt organ for overvåking av medisinsk obduksjonsvirksomhet kunne ligge under Dødsårsaksregisteret.

Oppgradering av fasiliteter er kritisk. Norge har ingen obduksjonssaler for agens ved smitterisikogruppe 3, for eksempel tuberkulose eller SARS-CoV-2, og smitterisikoobduksjoner utføres med «forsterkede» arbeidsprosedyrer (22). Tilgang til alle nødvendige spesialundersøkelser og mulighet for demonstrasjon av funn ved videooverføring må sikres.

Det er på høy tid at sentrale helsemyndigheter tar i bruk obduksjonsverktøyet. Skandaleoppslag om feil i helsetjenesten fører regelmessig til krav om mer effektive tilsynsordninger. At det allerede eksisterer fullverdige kvalitetssikringsordninger som ikke benyttes, er den egentlige skandalen.

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  295. Almanya’nın en iyi medyumu haluk hoca sayesinde sizlerde güven içerisinde çalışmalar yaptırabilirsiniz, 40 yıllık uzmanlık ve tecrübesi ile sizlere en iyi medyumluk hizmeti sunuyoruz.

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  300. Almanya’nın en çok tercih edilen medyumu haluk yıldız hoca olarak bilinmektedir, 40 yıllık tecrübesi ile sizlere en iyi bağlama işlemini yapan ilk medyum hocadır.

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  306. Merhaba Ben Haluk Hoca, Aslen Irak Asıllı Arap Hüseyin Efendinin Torunuyum. Yaklaşık İse 40 Yıldır Havas Ve Hüddam İlmi Üzerinde Sizlere 100 Sonuç Veren Garantili Çalışmalar Hazırlamaktayım, 1964 Yılında Irak’ın Basra Şehrinde Doğdum, Dedem Arap Hüseyin Efendiden El Aldım Ve Sizlere 1990 lı Yıllardan Bu Yana Medyum Hocalık Konularında Hizmet Veriyorum, 100 Sonuç Vermiş Olduğum Çalışmalar İse, Giden Eşleri Sevgilileri Geri Getirme, Aşk Bağlama, Aşık Etme, Kısmet Açma, Büyü Bozma Konularında Garantili Sonuçlar Veriyorum, Başta Almanya Fransa Hollanda Olmak Üzere Dünyanın Neresinde Olursanız Olun Hiç Çekinmeden Benimle İletişim Kurabilirsiniz.

  307. Almanya’nın en iyi güvenilir medyumunun tüm sosyal medya hesaplarını sizlere paylaşıyoruz, güvenin ve kalitelin tek adresi olan medyum haluk hoca 40 yıllık uzmanlığı ile sizlerle.

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  315. Medyum haluk hoca avrupanın en güvenilir medyum hocasıdır, sizlerinde bilgiği gibi en iyi medyumu bulmak zordur, biz sizlere geldik.

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  318. Ünlülerin tercih ettiği medyum hocamıza dilediğiniz zaman ulaşabilirsiniz, medyum haluk hocamız sizlerin daimi yanında olacaktır.

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  320. Birincisi güvenilir medyum hocaları bulmak olacaktır, ikinci seçenek ise en iyi medyumları bulmak olacaktır, siz hangisini seçerdiniz.

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  322. Dünyaca ünlü medyum haluk hoca, 40 yıllık uzmanlık ve tecrübesi ile sizlere en iyi hizmetleri vermeye devam ediyor, Aşk büyüsü bağlama büyüsü giden sevigiliyi geri getirme.

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  324. Dünyaca ünlü medyum haluk hoca, 40 yıllık uzmanlık ve tecrübesi ile sizlere en iyi hizmetleri vermeye devam ediyor, Aşk büyüsü bağlama büyüsü giden sevigiliyi geri getirme.

  325. Medyum sitesi medyum hocamızın web sayfasını sizlere en iyi şekilde tanıtıyoruz, güzel yorumlarınız içinde teşekkkür ediyoruz.

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