Table 1

Selected cases from Bayalpata Hospital's morbidity and mortality conference*

Age, sex	Primary diagnosis	Problems identified	Domains of Causal Analysis	Recommendations
20 years, woman	Intrauterine fetal demise	Laboratory staffing is insufficient at times of high patient volume	Clinical operations, Personnel	Additional training for nurses and mid-level practitioners should be conducted by lab personnel to enable lab task shifting during times of high patient volume
20 years, woman	Intrauterine fetal demise	There is a lack of trained ultrasonographers at the hospital	Clinical operations, Equipment, Personnel	Management should investigate options for off-site intensive training for a staff member
6 years, boy, 12 years, boy	Botulism poisoning	Clinicians are not in contact with private pharmacies and traditional healers in the villages	Clinical operations, Personnel, Outreach, Societal	Management should develop a list of contact information and meetings should be set up at the hospital and in the community for relationship building
28 years, man	Suicide attempt	There is a lack of mental health services in our catchment area	Clinical operations, Personnel, Structural	Medical director and management should develop emergency referral list and crisis line with psychiatrists in the capital
28 years, man	Suicide attempt	Pharmacy lacks any type of anti-depressant medications.	Clinical operations, Supply chains	Management should procure at least two different medicines and identify long-term suppliers
8 months, boy	Pneumonia	Oxygen tanks are unavailable locally, and pre-existing tanks cannot be refilled locally	Clinical operations, Equipment, Supply chains, Structural	Management should procure tanks and oxygen from the capital for the ER, inpatient wards, and the ambulance
8 months, boy	Pneumonia	AMBU bags are not easily accessible in emergency situations	Clinical operations, Equipment, Personnel	Senior nurse should identify a designated location for bag valve masks in the ER and inpatient wards, spaced in close proximity to all beds to avoid delays in administering care
19 years, woman	Retained placenta	Some mid-level practitioners and nurses are unfamiliar with basic resuscitation protocols	Clinical operations, Personnel	On-site protocol review should be conducted by the senior physicians
19 years, woman	Retained placenta	Limited pharmacy staffing leads to problems at times of high patient volume	Clinical operations, Personnel	The pharmacist should conduct task-shifting workshops for medicine dispensing and stocking for nurses and mid-level practitioners
35 years, woman	Motor vehicle accident	ER ultrasounds are not being administered in a timely fashion	Clinical operations, Equipment, Personnel	ER ultrasound utilisation protocols should be developed by physicians to ensure that patients receive urgent scans when indicated
87 years, man	COPD	Close observation of patients with COPD has been insufficient due to visibility from the nurses' station	Clinical operations, Personnel	Senior nurse should designate a specific bed in the ER for these patients with close observation and all necessary equipment in close proximity
87 years, man	COPD	The pharmacy lacks any inhalers.	Clinical operations, Supply chains	Management and the pharmacist should procure multiple types of inhalers for both inpatient and outpatient management of respiratory disease.
60 years, man	Tuberculosis	Tuberculosis diagnostic criteria are not being appropriately followed	Clinical operations, Equipment, Personnel	Clinicians and lab personnel should henceforth utilise both radiological and sputum-based diagnostic testing
60 years, man	Tuberculosis	Staff attend off-site training but do not share their new knowledge and skills with other staff	Clinical operations, Personnel	Management should institute post-training skill-sharing workshops for all staff members attending training
17 years, man	Head trauma	Patients in the ER wait for long periods of time even for simple items like intravenous fluids	Clinical operations, Equipment, Personnel	The medical director and senior nurse should institute standing orders for ER patients
36 years, woman	Antepartum haemorrhage	Partographs are being used inconsistently and improperly	Clinical operations, Equipment, Personnel	Physicians and senior nurse should conduct partograph training, along with beginning a programme to monitor weekly partograph completion rates and the review of all completed partographs
36 years, woman	Antepartum haemorrhage	Patient family members receive low-quality and inconsistent counselling in the ER	Clinical operations, Personnel, Societal	The medical director and management should identify a key person to provide counselling to ER patient family member

↵* Many of these M&Ms had several recommendations but for the purpose of this paper, we have simply provided a selection from each case.
COPD, chronic obstructive pulmonary disease; ER, emergency room.