Closing the gap: A workflow-based analysis of postconsent failure to restore hospital autopsy utilization

Hospital autopsy rates continue to decline despite their established role in diagnostic quality assurance, patient safety, and medical education. At our academic institution, autopsy utilization decreased to less than 1% of inpatient deaths. We hypothesized that this decline reflects failures within the autopsy workflow rather than limitations in consent acquisition. We analyzed 4229 inpatient deaths from 2019 to 2025 and performed a detailed audit of 140 autopsy consents to evaluate documentation quality, accuracy of indication, and involvement of pathology personnel. In addition, clinical resident physicians were surveyed using a six-scenario assessment to evaluate recognition of autopsy indications. Autopsy utilization declined from 3.9% to 0.57%, while the consent-to-autopsy conversion rate decreased from 52% to 8%, indicating substantial loss of cases after consent had been obtained. Forty percent of consents were incomplete or inaccurate, and pathology personnel were involved in only 1.4% of cases. Survey results demonstrated variable recognition of autopsy indications and infrequent consideration of autopsy in clinical practice. A workflow-based model showed that targeted improvements in consent quality and initiation could increase autopsy utilization up to 4.4-fold. These findings indicate that autopsy underutilization reflects modifiable system-level inefficiencies rather than solely cultural or financial barriers. A structured, workflow-based approach provides a reproducible framework to improve autopsy utilization and reestablish its role in quality assurance and medical education.