Why Did Mrs X Die? Understanding the Pathways to Maternal Death From: http://hamlin.org.au/what-we-do/

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

Short Exercise (10 minutes) Turn to 1-2 people next to you 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)

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

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