Adherence & Retention
Mortality Review Programs in Resource-Poor Areas
Our organization, Nyaya Health, has recently started a mortality review program in which we review all deaths that occur at our hospital in rural Nepal and identifying systems-level changes to prevent future deaths. See our recent blog post on the subject:
http://blog.nyayahealth.org/2009/10/29/mortalityreview/
By assessing the root causes of deaths, we hope to assess effectiveness, identify programmatic weaknesses, and make tangible improvements to clinical operations. We would appreciate any feedback on our approach, as well as links to similar such programs.
For example, we recently suffered a tragic death of a four-month old, likely secondary to bacterial pneumonia and sepsis seven days after she had been discharged from our hospital on amoxicillin for presumed pneumnonia. She lived two hours from the hospital, did not get better, received various traditional healing treatments, and returned essentially dead on arrival. Our discussions centered around inpatient observation and community follow-up to prevent such awful deaths in the future. The text of our mortality review is provided in the blog post itself.
http://blog.nyayahealth.org/2009/10/29/mortalityreview/
Thanks to all for your solidarity and insights.
Duncan Smith-Rohrberg Maru, MD, PHD
Resident Physician in Internal Medicine and Pediatrics
Harvard Brigham and Women’s and Boston Children’s Hospitals
Moses Bateganya
Dr Duncan Smith-Rohrberg Maru
Thank you for sharing this very innovative way of looking at causes of death. Often in many programs we forget to some operational issues as contributors to mortality.
Could you share some more how the findings are used to address the multiple factors? How do you use this system in mentoring health care workers to prevent similar problems? Is this part of the general quality improvement?
Moses Bateganya MMed, MPH
12:31 PM, 16 Nov 2009 | Permalink
Duncan Smith-Rohrberg Maru
Hi Moses,
Thank you for your comments. The program is part of a general vision of creating a more responsive health system. The idea is that by reflecting on deaths-- in some ways the ultimate arbiter of epidemiological and clinical truth-- we can improve how we operate as a team. As with any well-functioning M&M review, the aim is not to assign blame but rather to identify systems-levels issues. For specifics of how this actually functions to (potentially) bring about change, I would refer you to our most recent case discussions on three tragic deaths:
http://wiki.nyayahealth.org/MortalityData#MortalityReviewCasesnbspnbsp
Regards,
Duncan
6:34 AM, 20 Nov 2009 | Permalink