Table 1

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

Age, sexPrimary diagnosisProblems identifiedDomains of Causal AnalysisRecommendations
20 years, womanIntrauterine fetal demiseLaboratory staffing is insufficient at times of high patient volumeClinical operations, PersonnelAdditional training for nurses and mid-level practitioners should be conducted by lab personnel to enable lab task shifting during times of high patient volume
There is a lack of trained ultrasonographers at the hospitalClinical operations, Equipment, PersonnelManagement should investigate options for off-site intensive training for a staff member
6 years, boy, 12 years, boyBotulism poisoningClinicians are not in contact with private pharmacies and traditional healers in the villagesClinical operations, Personnel, Outreach, SocietalManagement 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, manSuicide attemptThere is a lack of mental health services in our catchment areaClinical operations, Personnel, StructuralMedical director and management should develop emergency referral list and crisis line with psychiatrists in the capital
Pharmacy lacks any type of anti-depressant medications.Clinical operations, Supply chainsManagement should procure at least two different medicines and identify long-term suppliers
8 months, boyPneumoniaOxygen tanks are unavailable locally, and pre-existing tanks cannot be refilled locallyClinical operations, Equipment, Supply chains, StructuralManagement should procure tanks and oxygen from the capital for the ER, inpatient wards, and the ambulance
AMBU bags are not easily accessible in emergency situationsClinical operations, Equipment, PersonnelSenior 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, womanRetained placentaSome mid-level practitioners and nurses are unfamiliar with basic resuscitation protocolsClinical operations, PersonnelOn-site protocol review should be conducted by the senior physicians
Limited pharmacy staffing leads to problems at times of high patient volumeClinical operations, PersonnelThe pharmacist should conduct task-shifting workshops for medicine dispensing and stocking for nurses and mid-level practitioners
35 years, womanMotor vehicle accidentER ultrasounds are not being administered in a timely fashionClinical operations, Equipment, PersonnelER ultrasound utilisation protocols should be developed by physicians to ensure that patients receive urgent scans when indicated
87 years, manCOPDClose observation of patients with COPD has been insufficient due to visibility from the nurses' stationClinical operations, PersonnelSenior nurse should designate a specific bed in the ER for these patients with close observation and all necessary equipment in close proximity
The pharmacy lacks any inhalers.Clinical operations, Supply chainsManagement and the pharmacist should procure multiple types of inhalers for both inpatient and outpatient management of respiratory disease.
60 years, manTuberculosisTuberculosis diagnostic criteria are not being appropriately followedClinical operations, Equipment, PersonnelClinicians and lab personnel should henceforth utilise both radiological and sputum-based diagnostic testing
Staff attend off-site training but do not share their new knowledge and skills with other staffClinical operations, PersonnelManagement should institute post-training skill-sharing workshops for all staff members attending training
17 years, manHead traumaPatients in the ER wait for long periods of time even for simple items like intravenous fluidsClinical operations, Equipment, PersonnelThe medical director and senior nurse should institute standing orders for ER patients
36 years, womanAntepartum haemorrhagePartographs are being used inconsistently and improperlyClinical operations, Equipment, PersonnelPhysicians 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
Patient family members receive low-quality and inconsistent counselling in the ERClinical operations, Personnel, SocietalThe 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.