Table 4

 Omissions in care*, constraints to optimal management and locus of responsibility

Omissions in careConstraints to optimal management
*Omissions in bold are those that were considered a primary factor for deaths in 2000–1.4
• Absent• Outpatient staff unaware that severe malnutrition cases have priority
• 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
• 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
• 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
• 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 imbalanceDOCTORS
• potassium, magnesium not prescribed• lack of knowledge that potassium is essential
• incorrect amounts prescribed• poor labelling of bottles; doses on bottles unclear
• gentamicin not prescribed• lack of knowledge that aggressive antibiotic treatment is necessary when child has complications
• incorrect amounts of antibiotics prescribedNURSES
• drugs not dispensed on time• poor basic nursing skills; poor motivation
• poor hygiene• re-ordering left too late
• no check to see if child is fed appropriately• unaware of the central role that feeding has in recovery
• not seen as doctors’ role