Omissions in care*, constraints to optimal management and locus of responsibility
| Omissions in care | Constraints to optimal management | |
|---|---|---|
| *Omissions in bold are those that were considered a primary factor for deaths in 2000–1.4 | ||
| Triage | DOCTORS/NURSES/MANAGERS | |
| • Absent | • Outpatient staff unaware that severe malnutrition cases have priority | |
| Hypoglycaemia | NURSES | |
| • children not fed by NG tube when intake <80% of target | • feeds unsupervised; intakes unreliable | |
| • danger signs overlooked | • carers do not know they should report if child becomes drowsy | |
| Hypothermia | NURSES | |
| • cold children overlooked | • minimal nurse/child contact | |
| • danger signs overlooked | • poor basic nursing skills; temperatures not measured | |
| • children left wet | • carers do not know to report cold child | |
| • no active rewarming | • linen shortage; linen locked away at night | |
| Dehydration/overhydration | DOCTORS | |
| • inadequate fluid management during new/continuing episodes of diarrhoea | • no daily ward round | |
| • fluid overload not prevented | • rehydration instructions to nurses unclear | |
| • no instructions to nurses to monitor child during rehydration to prevent fluid overload | ||
| • incorrect fluid volumes prescribed | ||
| NURSES | ||
| • carers fail to report diarrhoea/vomiting | ||
| • carers use ORS without supervision, tamper with intravenous fluids | ||
| • ORS volume not recorded | ||
| • child not monitored when given intravenous fluid or oral fluids | ||
| Electrolyte imbalance | DOCTORS | |
| • potassium, magnesium not prescribed | • lack of knowledge that potassium is essential | |
| • incorrect amounts prescribed | • poor labelling of bottles; doses on bottles unclear | |
| Infection/sepsis | DOCTORS | |
| • gentamicin not prescribed | • lack of knowledge that aggressive antibiotic treatment is necessary when child has complications | |
| • incorrect amounts of antibiotics prescribed | NURSES | |
| • drugs not dispensed on time | • poor basic nursing skills; poor motivation | |
| • poor hygiene | • re-ordering left too late | |
| Feeding | DOCTORS | |
| • no check to see if child is fed appropriately | • unaware of the central role that feeding has in recovery | |
| • not seen as doctors’ role | ||