Review Of Deaths Research Articles

Knowledge and Practices of Doctors About Patient Safety Working at Primary and Secondary Level Health Care Facilities in Bangladesh

Aim: This descriptive type of cross sectional study was conducted with an objective to evaluate the views of doctors regarding knowledge and practices about patient safety working at primary and secondary level health care facilities in Bangladesh.
 Methods: Study period was from August 2016 to December 2016. Multistage, convenience sampling was done . Sample size was 550. Self administered semi structured questionnaire was used for data collection after pre testing. Data was collected by principle investigator , co-investigator & data collectors. Data was also collected by sending questionnaire by postage followed by a focal group discussion.
 Results: Result showed 70 % were male and 57% were primary level medical officers. 44.9% understands patients safety. 51.1% understands medical errors . 37.5% agreed that less duty hours will reduce medical errors . 62% strongly agreed that Learning about patient safety will enhance competency. 44.5% agreed that undergraduate course prepared them to ensure patient safety. 37.5 % agreed that they learned about medical errors during their undergraduate course. 40.6% stated that they were assigned to perform the tasks for which they were not trained competently, 34% said that they were assigned to perform the tasks which could have resulted easily in medical errors . Most of the respondents strongly agreed that teaching about patient safety should be an important priority. 46% stated that these should be in clinical teaching and 40% stated the same to be in bed side teaching . 24% stated that there were not enough topics in the existing curriculum regarding patient safety. 46% confessed that they made medical errors during their practices. 33% stated that they want patient safety education in their professional practice, 76.9% strongly agreed that patient safety is an important issue in their professional practices and 44% sensitizes their colleagues about patient safety to learn & practices. 54.7% stated that they did not have error reporting system/ death review/ medical audit in their hospital, 89.7% did not have attended any training on patient safety . 90% thought that training on patient safety is essential for doctors 67.2% respondents opined that there should be a competent organization / body who can take care of patient safety & medical errors in Bangladesh.
 Conclusion: The study reflects that many primary level medical officers do not understand patients safety and medical errors. The study also showed that most of them has a positive attitude torwards patient safety. Study recommended that doctors serving at primary and secondary level healthcare facilities to be oriented/ trained on different aspects of patient safety
 J Bangladesh Coll Phys Surg 2020; 38(1): 5-11

Maternal death review and surveillance: The case of Central Hospital, Benin City, Nigeria.

BackgroundDespite the adoption of Maternal and Perinatal Death Surveillance and Response (MPDSR) by Nigeria’s Federal Ministry of Health to track and rectify the causes of maternal mortality, very limited documentation exists on experiences with the method and its outcomes at institutional and policy levels.ObjectiveThe objective of this study was to identify through the MPDSR process, the medical causes and contributory factors of maternal mortality, and to elucidate the policy response that took place after the dissemination of the results.MethodsThe study was conducted at the Central Hospital, Benin between October 1, 2017, and May 31, 2019. We first developed a strategic plan with the objective to reduce maternal mortality by 50% in the hospital in two years. An MPDSR committee was established and the members and all staff of the Maternity Department of the hospital were trained to use the nationally approved protocol. All consecutive cases of maternal deaths in the hospital were then reviewed using the MPDSR protocol. The results were submitted to the hospital Management and its supporting agencies for administrative action to correct the identified deficiencies.ResultsThere were 18 maternal deaths in the hospital during the period, and 4,557 deliveries giving a maternal mortality ratio (MMR) of 395/100,000 deliveries. This amounted to a seven-fold reduction in MMR in the hospital at the onset of the project. The main medical causes identified were obstetric hemorrhage (n = 10), pulmonary embolism (n = 2), ruptured uterus (n = 2), eclampsia (n = 1), anemic heart failure (n = 1) and post-partum sepsis (n = 2). Several facility-based and patient contributory factors were identified such as lack of blood in the hospital and late reporting with severe obstetric complication among others. Response to the recommendations from the committee include increased commitment of hospital managers to immediately rectify the attributable causes of deaths, the establishment of a couples health education program, mobilization and sensitization of staff to handle pregnant women with great sensitivity, promptness and care, the refurbishing of an intensive care unit, and the increased availability of blood for transfusion through the intensification of blood donation drive in the hospital.ConclusionWe conclude that the results of MPDSR, when acted upon by hospital managers and policymakers can lead to an improvement in quality of care and a consequent decline in maternal mortality ratio in referral hospitals.

Assessment of knowledge and Practices of Midwives in Labor Room Regarding Infection Control in the Main Governmental Hospitals at Sana'a city

Background: Infection control is a more substantial area of concern in labor and delivery room where nosocomial infection can be acquired in the maternal and child health facility. This study aimed to assess knowledge and practice of midwives in labor room regarding infection control. Design: A descriptive cross-sectional design was conducted. Setting: five main governmental hospitals at Sana'a city. Subjects: 84 midwives who work in delivery rooms were selected. Tools: two tools were used tool I: structured questionnaire consist of two parts, part 1: demographic data and part 2 to assess their knowledge related to universal precaution, tool II: checklist was used to assess the practice. Results: the total knowledge about universal precaution and infection control, slightly more than half of the subjects had good knowledge whereas few had poor knowledge. The majority of them had excellent practice for universal precaution and the there was no statistical significant between total knowledge score and total practice score. Conclusion: The total score of midwife’s knowledge related to universal precaution of infection control in the delivery units was fairly enough and the majority of them had excellent score of practice. Recommendations: There should be active hospital infection control committees set up, combined with maternal death reviews, audits, training and feedback on infection rates.

Understanding cause of stillbirth: a prospective observational multi-country study from sub-Saharan Africa

BackgroundEvery year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). There is a paucity of primary data on cause of stillbirth from LMIC, and particularly from sub-Saharan Africa to inform effective interventions. This study aimed to identify the cause of stillbirths in low- and middle-income settings and compare methods of assessment.MethodsThis was a prospective, observational study in 12 hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe. Stillbirths (28 weeks or more) were reviewed to assign the cause of death by healthcare providers, an expert panel and by using computer-based algorithms. Agreement between the three methods was compared using Kappa (κ) analysis. Cause of stillbirth and level of agreement between the methods used to assign cause of death.ResultsOne thousand five hundred sixty-three stillbirths were studied. The stillbirth rate (per 1000 births) was 20.3 in Malawi, 34.7 in Zimbabwe, 38.8 in Kenya and 118.1 in Sierra Leone. Half (50.7%) of all stillbirths occurred during the intrapartum period.Cause of death (range) overall varied by method of assessment and included: asphyxia (18.5–37.4%), placental disorders (8.4–15.1%), maternal hypertensive disorders (5.1–13.6%), infections (4.3–9.0%), cord problems (3.3–6.5%), and ruptured uterus due to obstructed labour (2.6–6.1%). Cause of stillbirth was unknown in 17.9–26.0% of cases.Moderate agreement was observed for cause of stillbirth as assigned by the expert panel and by hospital-based healthcare providers who conducted perinatal death review (κ = 0.69; p < 0.0005). There was only minimal agreement between expert panel review or healthcare provider review and computer-based algorithms (κ = 0.34; 0.31 respectively p < 0.0005).ConclusionsFor the majority of stillbirths, an underlying likely cause of death could be determined despite limited diagnostic capacity. In these settings, more diagnostic information is, however, needed to establish a more specific cause of death for the majority of stillbirths. Existing computer-based algorithms used to assign cause of death require revision.

Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors

Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, 4 state health departments (Georgia, Louisiana, Michigan, and Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates. To estimate the validity of the pregnancy checkbox on the death certificate, and to describe characteristics associated with errors using 2016 data from a 4-state quality assurance pilot. Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within 1 year preceding death or by pregnancy checkbox status. Death certificates that indicated that the decedent was pregnant within 1 year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type. Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. A total of 97 women (21%) were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (P < .001). Deaths certified by coroners and medical examiners were more likely to be confirmed pregnant than confirmed not pregnant (P= .04). The association between decedent age category and false-positive status followed a dose-response relationship (P < .001), with increasing prevalence ratios for each increase in age category. Death certificates of non-Hispanic black women were more likely to be false positive, compared with non-Hispanic white women (prevalence ratio, 1.41; 95% confidence interval, 1.01, 1.96). The sensitivity of the pregnancy checkbox among these 4 states in 2016 was 62% and the positive predictive value was 68%. We provide a multi-state analysis of the validity of the pregnancy checkbox and highlight a need for more accurate reporting of pregnancy status on death certificates. States and other jurisdictions may increase the accuracy of their data used to calculate maternal mortality rates by implementing quality assurance processes.

Pragmatic approach to halt preventable maternal and neonatal deaths in Nigeria

Objectives: The objective of the paper is to promote a pragmatic approach to stem high maternal and neonatal mortality in Nigeria as it is becoming increasingly evident that ending preventable maternal and neonatal deaths goes beyond counting the numbers. Methods: A literature search was performed of Pub Med, HINARI, Google scholar using keywords in the review to build a set of search terms. Reference lists of all the included studies were scanned to identify additional relevant studies. Results: Facility-based death review, review of near-miss and clinical audit are quality improvement methods and on their own are health care interventions. Conclusion: Though findings from reviews and audit provide actionable information, the commitment of health care providers to act on the information is key to achieving the purpose of reviews and audits. There is need to invest in health system researches that focus on quality improvements in maternal and neonatal care in Nigeria. Keywords: audit, review, quality, improvement

Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects.

BackgroundMaternal and Perinatal Death Surveillance and Response (MPDSR) was a pilot program introduced in Tigray, Ethiopia to monitor maternal and perinatal death. However; its implementation and operation is not evaluated yet. Therefore, this study aimed to assess the implementation and operational status and determinants of MPDSR using a programmatic data and stakeholders involved in the program.MethodsInstitutional based cross-sectional study was applied in public health facilities (75 health posts, 50 health centers and 16 hospitals) using both qualitative and quantitative methods. Data were entered in to Epi-info and then transferred to SPSS version 21 for analysis. All variables with a p-value of ≤ 0.25 in the bivariate analysis were included in to multivariable logistic regression model to identify the independent predictors. For the qualitative part, manual thematic content analysis was done following data familiarization (reading and re-reading of the transcripts).ResultsIn this study, only 34 (45.3%) of health posts were practicing early identification and notification of maternal/perinatal death. Furthermore, only 36 (54.5%) and 35(53%) of health facilities were practiced good quality of death review and took proper action respectively following maternal/perinatal deaths. Availability of three to four number of Health Extension Workers (HEWs) (Adjusted Odds Ratio (AOR) = 6.09, 95%CI (Confidence Interval): 1.51–24.49), availability of timely Public Health Emergency Management (PHEM) reports (AOR = 4.39, 95%CI: 1.08–17.80) and participation of steering committee’s in death response (AOR = 9.19, 95%CI: 1.31–64.34) were the predictors of early identification and notification of maternal and perinatal death among health posts. Availability of trained nurse (AOR = 3.75, 95%CI: 1.08–12.99) and health facility’s head work experience (AOR = 3.70, 95%CI: 1.04–13.22) were also the predictors of quality of death review among health facilities. Furthermore; availability of at least one cluster review meeting (AOR = 4.87, 95%CI: 1.30–18.26) and uninterrupted pregnant mothers registration (AOR = 6.85, 95%CI: 1.22–38.54) were associated with proper response implementation to maternal and perinatal death. Qualitative findings highlighted that perinatal death report was so neglected. Community participation and intersectoral collaboration were among the facilitators for MPDSR implementation while limited human work force capacity and lack of maternity waiting homes were identified as some of the challenges for proper response implementation.ConclusionThis study showed that the magnitude of: early death identification and notification, review and response implementation were low. Strengthening active surveillance with active community participation alongside with strengthening capacity building and recruitment of additional HEWs with special focus to improve the quality of health service could enhance the implementation of MPDSR in the region.

Streamlined system marks new era for safeguarding children

Replacing LSCBs with partnerships between councils, police and CCGs will lead to more regional working and thematic reviews of child deaths. Advocates say this will improve learning, but concerns remain over leadership

Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions.

The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths are declining. Cardiomyopathy and other cardiovascular conditions, hemorrhage, and other chronic medical conditions are all important causes of death. Unintentional death from violence, overdose, and self-harm are emerging causes that require medical and public health attention. Significant racial/ethnic inequities exist in pregnancy care with non-Hispanic black women incurring 3 to 4 times higher rates of pregnancy-related death than non-Hispanic white women. Varied terminology and lack of standardized methods for identifying maternal deaths in the United States have resulted in nuanced data collection and interpretation challenges. State maternal mortality review committees are important mechanisms for capturing and interpreting data on cause, timing, and preventability of maternal deaths. Importantly, a thorough standardized review of each maternal death leads to recommendations to prevent future pregnancy-associated deaths. Key interventions to improve maternal health outcomes include 1) integrating multidisciplinary care for women with high-risk comorbidities during preconception care, pregnancy, postpartum, and beyond; 2) addressing structural racism and the social determinants of health; 3) implementing hospital-wide safety bundles with team training and simulation; 4) providing patient education on early warning signs for medical complications of pregnancy; and 5) regionalizing maternal levels of care so that women with risk factors are supported when delivering at facilities with specialized care teams.

Appendicectomy mortality: an Australian national audit.

Appendicectomy is a safe surgical procedure with minimal risks. Low mortality rates (0.04-0.24%) have been reported from a number of countries. Appendicectomy mortality rates have not been reported in Australia in recent years. The aim of the study was to conduct an appendicectomy mortality audit, to identify clinical management issues and to calculate the mortality rate of appendicectomy in Australia. This study analysed data from a peer review of appendicectomy deaths in Australian hospitals of all states and territories, from 2006 to 2017. Additional procedural data were obtained from the Australian Institute of Health and Welfare for the calculation of mortality rates. The final analysis included 82 patients of whom 62 were elderly (age >65 years) with 47 males and 35 females. Two or more comorbidities were present in 68 patients. Open operation was performed in 62 patients, with complicated appendicitis found in 50 cases. The majority of management issues were non-surgical. Of the 16 surgical management issues identified, 11 issues occurred post-operatively in the elderly, which were potentially preventable. The overall mortality was 0.02% with 0.01% in the young (age <65 years) and 0.20% in the elderly. Australia's appendicectomy mortality rate was very low and comparable to international figures. Surgical management of appendicectomy was satisfactory in general. However, post-operative care in the elderly was found to be poor at times, with room for improvement. Further research is needed whether improvements in post-operative care could alter the clinical course to death in the elderly.

National child death review statutory and operational guidance: Key concepts for practising paediatricians

In October 2018, National Health Service England published new operational guidance for reviewing child deaths, which covers all children who die less than 18 years of age regardless of the...

Patterns of Anatomic Injury in Critically Injured Combat Casualties: A Network Analysis

A mortality review of death caused by injury requires a determination of injury survivability prior to a determination of death preventability. If injuries are nonsurvivable, only non-medical primary prevention strategies have potential to prevent the death. Therefore, objective measures are needed to empirically inform injury survivability from complex anatomic patterns of injury. As a component of injury mortality reviews, network structures show promise to objectively elucidate survivability from complex anatomic patterns of injury resulting from explosive and firearm mechanisms. In this network analysis of 5,703 critically injured combat casualties, patterns of injury among fatalities from explosive mechanisms were associated with both a higher number and severity of anatomic injuries to regions such as the extremities, abdomen, and thorax. Patterns of injuries from a firearm were more isolated to individual body regions with fatal patterns involving more severe injuries to the head and thorax. Each injury generates a specific level of risk as part of an overall anatomic pattern to inform injury survivability not always captured by traditional trauma scoring systems. Network models have potential to further elucidate differences between potentially survivable and nonsurvivable anatomic patterns of injury as part of the mortality review process relevant to improving both the military and civilian trauma care systems.

Barriers to safety for victims of domestic homicide

ABSTRACTResearch on domestic homicide has focused on risk factors presented by perpetrators such as prior violence, threats to kill, stalking, access to weapons, mental health concerns, controlling behaviour and separation. However, there has been less focus on the barriers that victims face regarding finding support, increasing personal safety and decreasing violence and risk of homicide. The present study explored 20 potential barriers that female domestic homicide victims faced using 183 cases occurring between 2002 and 2012 from the Ontario (Canada) Domestic Violence Death Review Committee to examine the presence and frequency of these barriers within the sample. Using two-step cluster analysis, different profiles of barriers were identified that centred on victims’ fear, social isolation and mental health. The study is limited in being a post hoc analysis of homicides and no causal links can be made. The implications of this finding are discussed in the context of risk assessment, risk management and safety planning.

PC-FACS

PC-FACS

Retrospective review of maternal deaths in Hawassa Comprehensive Specialised Hospital, in Southern Ethiopia

The aim of this study was to evaluate the causes of and contributors to maternal death at Hawassa Referral Comprehensive Specialised Hospital (HRCSH). A health facility–based, maternal death review was used. All maternal deaths that occurred between January 2016 and August 2017 in HRCSH were included. Data were collected using a structured data collection sheet and analysed. Eighty-two maternal deaths that occurred over a 20-month period were reviewed, of which 77 met the inclusion criteria. A total of 8466 births occurred in HRCSH during the study period. The overall facility-based maternal mortality rate (MMR) was 910 deaths per 100,000 live births. The majority of maternal deaths (69 deaths; 89.6%) were due to direct causes, with pregnancy-induced hypertension as the leading direct cause of 33 deaths (42.8%). Eight avoidable factors were identified in this review. Twenty-six patients (33.9%) died as a result of a combination of three or more factors. Patient-oriented and transport/referral factors were the most common avoidable factors, with each contributing to 62 deaths (80.5%). Prenatal patients would benefit from receiving information regarding danger signs that could assist in the early detection of health problems and increase the likelihood that they seek health care.Impact StatementWhat is already known on this subject? Most maternal deaths are preventable. However, maternal mortality rates remain high despite the presence of multiple measures in the southern part of Ethiopia. There is no adequate information about the maternal death rate in the study setting.What do the results of this study add? Hawassa Referral Comprehensive Specialised Hospital is a regional health centre. This study found that combinations of several factors may be contributing to a high maternal death rate. Most notably, transport, delay management initiation after admission and referral factors account for the majority of maternal deaths.What is the implication of these findings for clinical practice/or further research? Identification of potential problems could assist context-based management of problems. It helps in improving the level of practical skills for the management of pregnancy-related complications like hypertension. It also solves problems in the health services system like access to interventions. It insists on intersectoral collaboration to solve the transportation problems.

Maternal mortality at the National Referral Hospital in Honiara, Solomon Islands over a five-year period.

The Solomon Islands is a developing country facing significant barriers to the provision of quality antenatal and obstetric care. The maternal mortality rate is 114/100000 live births, ranking the Solomon Islands 113th globally. Investigating maternal mortality may yield valuable insight into improving these numbers. The objective of this study was to review all cases of maternal mortality at the National Referral Hospital, Solomon Islands over a five-year period. This was a retrospective review of maternal deaths occurring at the National Referral Hospital, Solomon Islands from 2013 to 2017. Data on maternal demographics, characteristics and cause of death were collected. There were 39 maternal deaths at the National Referral Hospital from 2013 to 2017. The maternal mortality rate of the National Referral Hospital (139/100000) is higher than the national rate (114/100000). Most deaths were direct, with 28% attributed to haemorrhage. Overall, 79% of the total maternal deaths had elements that may be considered preventable, with laboratory delays present in 54% and medication shortages present in 29% of cases. Maternal mortality is high in the Solomon Islands, with many potentially preventable deaths occurring at the National Referral Hospital. Continued focus on improving data collection, access to resources, and training is vital to reduce maternal mortality in the Solomon Islands.

Systemic predictors of adverse events in a national surgical mortality audit: analysis of peer-review data from Australia and New Zealand Audit of Surgical Mortality.

Peer review of surgical deaths can identify deficits in individual and systemic delivery of healthcare, ultimately informing quality improvement. From 2008 to 2016, cases reported to the Australia and New Zealand Audit of Surgical Mortality were analysed. Variables associated with peer-judged adverse events were sought. Of 21 045 cases evaluated, 24.8% incurred at least one adverse event judgement. The proportion of cases with reported adverse event significantly decreased over time. Following adjustment for demographic and clinical characteristics, significant negative patient-related associations were advanced age, greater American Society of Anesthesiologists grade, and neurological and malignant comorbidities. Significant associations were also found with systemic or organizational factors, including state/territory, surgical specialty and hospital regionality. Examination of this peer-reviewed database revealed systemic or organizational predictors of adverse events that may have implications for quality improvement at an institutional or jurisdictional level. The extent to which these associations are due to the peer-review process itself should be the focus of further research.

Homicides and Maltreatment‐related Deaths of Disabled Children: A Systematic Review

This article aims to systematically review the empirical literature in relation to the homicides and maltreatment‐related deaths of disabled children in order to better understand the risk factors and to assess support for the explanatory theories posited. These theories include: (1) the stress of caregiving; (2) altruistic intent; (3) lack of bonding with the child; (4) the challenging behaviours the child; (5) cultural beliefs about disabled children; and (6) evolutionary imperatives. Systematic searching techniques were used to retrieve relevant research articles in six electronic databases: AMED, CINAHL, Criminal Justice Abstracts, Medline (PubMed), PsycINFO and SCOPUS. The issue of a child being disabled was identified as a risk factor in most reviewed articles, however the definition of the term ‘disability’ was not consistent nor was there a consistent approach to recording children's disability. A range of potential risk factors were found, relating to the child, the perpetrator and the environment, with the pathway to harming the child involving an interactive process between each of these. The stress of caregiving and altruistic theories were the two most common explanations for homicides and maltreatment‐related deaths of disabled children, although a combination of theories may provide a more comprehensive explanation of these complex events.‘This article aims to systematically review the empirical literature in relation to the homicides and maltreatment‐related deaths of disabled children’Key Practitioner Messages Coordination of clear care pathways for families with disabled children, including the provision of support and counselling. Improved professional awareness of the needs of disabled children and understanding that these needs may not coincide with those of their parents or carers. Provision of opportunities for respite to enable parents of disabled children to continue their task of caring. Need for consistent data on disabled children to be collected through existing child death review processes and the criminal justice system.

Strengthening the \u201cP\u201d in Maternal and Perinatal Death Surveillance and Response in Bungoma county, Kenya: implications for scale-up

BackgroundThis paper examines perinatal death reporting and reviews in Bungoma county, Kenya, where substantial progress has been made, providing important insights for wider scale up to other contexts.MethodsQuantitative methods were used to analyse trends in perinatal death reporting and reviews between 2014 and 2017 throughout Kenya based on data from the District Health Information System. Qualitative methods helped further understand the success of perinatal death reporting and review in Bungoma county through focus group discussions and individual interviews at 5 hospitals and 1 health centre. Thematic analysis was used to draw out codes for the analysis.ResultsOnly 13 of the 47 counties in Kenya conduct perinatal death reviews. In 2017, the year after the perinatal death review system was introduced, only 3.6% of perinatal deaths were reviewed in Kenya. Bungoma county has made the greatest strides in Kenya, reviewing 59% of the perinatal deaths that occurred within the county in 2017. Bungoma accounted for 51% of all the perinatal deaths reviewed in Kenya. Factors contributing to the success in Bungoma include harmonisation of facility based perinatal reporting tools with the national level; prioritising the need to document and report mortalities; tailoring continual medical education and supportive supervision visits to needs identified from the review; and better documentation and referral processes. Supportive management and administrative staff have also helped drive forward implementation of actions and increased health staff motivation to reduce perinatal deaths and improve quality of care.ConclusionsSuccessful implementation of perinatal death reviews requires clear delineation of roles and responsibilities for action, which are routinely monitored to track implementation progress. As in other low-income settings, Bungoma county has demonstrated that in Kenya, perinatal death reviews can be effectively implemented and sustained, through a focus on learning, solution-oriented responses, influencing those in a power to act, accountability for results, and observable quality of care improvements.

Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital's Ten Years' Experience 2008-2017.

Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI). In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety. In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease. Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.