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Table 3 Factors contributing to maternal deaths in Botswana 2010 Contributory factors identified (multiple categories apply) N = 55

From: A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement

 

Direct

Indirect

Total

% cases

Organizational and/or management total

(42)

(89)

47

84

1. Lack of, or failure to implement, policies, protocols, guidelines

8

16

24

44

2. Poor organizational arrangements of staff

0

19

19

35

3. Inadequate education and training

10

8

18

33

4. Poor team work

5

12

17

31

5. Delayed ordering investigations, access to test results or inaccurate results

4

12

16

29

6. Poor access to senior clinical staff

7

8

14

25

7. Inadequate systems/process for sharing clinical information between services: all HV positive

1

10

11

20

8. Failure or delay in emergency response

5

3

8

15

9. Delay in intervention or procedure eg C-section

2

1

3

5

10. Inadequate numbers of staff

UK

UK

UK

UK

Personnel total

(62)

(96)

49

88

11. Lack of recognition of complexity/seriousness of condition

14

25

39

71

12. Lack of knowledge and skills of staff (includes failure to maintain competence, making wrong diagnoses, lack of differential diagnoses leading to linear decision making)

12

25

37

67

13. Failure to offer or follow recommended best practice

11

18

29

53

14. Failure to seek help/supervision/consultation/delay in physician/ICU/anaesthetic consultation

9

10

19

35

15. Failure of communication between staff (entries in medical notes used to communicate between doctors and nurses)

5

11

16

29

16. Delayed emergency response by staff

8

4

12

22

17. Failure of communication of staff with patient or family

3

3

6

11

Technology, equipment and supplies total

(5)

(11)

14

27

18. Supplies (IV fluids, blood for transfusion, drugs etc.) out of stock

4

8

12

22

19. Non-availability, malfunction or failure of essential equipment

1

3

4

7

Environment (1 case, 2%)

  

1

2

20. Geography eg long distance transfer

1

 

1

2

Barriers to accessing or engaging with care total

(18)

(21)

29

53

21. Did not attend for ANC, only had one ANC visit, or late booking

8

12

20

37

22. Not eligible to access free care (non-citizens)

7

4

11

20

23. Lack of recognition of complexity/seriousness of condition by either woman or her family

1

4

5

9

24. Maternal learning disability

 

1

1

2

25. Cultural barriers (attended traditional healer first)

1

 

1

2

26. Social circumstances

1

 

1

2

  1. Adapted from Farquhar et al. 2011[1].