"As a result, causes of death not associated with an ICD code, such as human and system factors, are not captured," according to The BMJ study.
The authors called for better reporting of medical error on death certificates.
Medical error is defined as an unintended act, one that does not achieve intended outcome, failure of planned action or errors of execution, or deviation from the process of care that could result in harm to the patients.
The study's authors cited the case of a young woman who was recovering well from transplant surgery, but then was readmitted to the hospital "for non-specific complaints that were evaluated with extensive tests, some of which were unnecessary, including a pericardiocentesis."
"She was discharged but came back to the hospital days later with intra-abdominal hemorrhage and cardiopulmonary arrest. An autopsy revealed that the needle inserted during the pericardiocentesis grazed the liver causing a pseudoaneurysm that resulted in subsequent rupture and death," the authors wrote.
"The death certificate listed the cause of death as cardiovascular," they said.
The authors wrote while "human error is inevitable" and "we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility and consequences."
They said there are three strategies which should be deployed to reduce the numbers of deaths from medical error. "Making errors more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients; and making errors less frequent by following principles that take human limitations into account," the authors wrote.