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Why Did Mrs X Die? Understanding the Pathways to Maternal Death From:

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Presentation on theme: "Why Did Mrs X Die? Understanding the Pathways to Maternal Death From:"— Presentation transcript:

1 Why Did Mrs X Die? Understanding the Pathways to Maternal Death From:

2 Understanding the “pathway to death” Video Why Did Mrs. X Die?

3 Short Exercise (10 minutes) 1.Turn to 1-2 people next to you 2.Discuss the video with the following in mind:  What was the direct cause of Mrs. X’s death  Were there any indirect causes?  What evidence did the review committees use to make changes in quality of care at the facility?  List 2 actions resulting from the analysis of Mrs. X’s death taken at the hospital and nationally)

4 Cycle of Data Collection, Reflection & Action IDENTIFY THE PROBLEM COLLECT DATA PRESENT DATA IN USEFUL FORMATS DISCUSS DATA WITH RELEVANT PEOPLE ANALYSE DATA PROPOSE SOLUTIONS IMPLEMENT RECOMMENDATIONS MONITOR ACTIONS & ADAPT IF REQUIRED

5 Cycle of Data Collection, Reflection & Action IDENTIFY THE PROBLEM COLLECT DATA PRESENT DATA IN USEFUL FORMATS DISCUSS DATA WITH RELEVANT PEOPLE ANALYSE DATA PROPOSE SOLUTIONS IMPLEMENT RECOMMENDATIONS MONITOR ACTION & ADAPT IF REQUIRED REVIEW ACTION EVIDENCE


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