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SUPPLEMENTAL: When things go wrong - Lucian Leape, Linda Kenney [Full text]

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No Fault Approach to building an audit of morbidity and mortality system

Joseph N.E. Ana, calabar, Nigeria   (30 May 2007)

No Fault Approach to building an audit of morbidity and mortality system 30 May 2007
Joseph N.E. Ana, Chairman, BMJ West Africa Group BMJWA edition, 20 Eta Agbor Road, calabar, Nigeria Send response to journal: Re: No Fault Approach to building an audit of morbidity and mortality system	When things go wrong in health care delivery there are usually multiple reasons and multiple levels that can be held accountable. Where the personnel are implicated some go to great lenghts to conceal their part in the error thereby depriving themselves and their colleagues the opportunity to discuss the error, plan and effect change to prevent future reoccurence of the same error. In 2004 in Cross River State of Nigeria, which has one of the highest maternal and child morbidity and mortality, most of it iatrogenic, we designed the first ever programmic state health plan 2004-2007, after a very comprehensive needs assessment. We adopted the Motto of the ministry as 'protecting patients whilst supporting health practitioners'and established a 'centre for clinical governance, research and training through servicom'in Calabar the state capital. The centre supervises a monthly cross river audit of morbidity and mortality (CRAMM) involving all health practitioners in the state including the administrators. To enlist the cooperation of all stakeholders in the scheme we have started it on a No Fault basis with the expressed understanding that where criminal conduct is uncovered the Law will ofcourse take its course but otherwise CRAMM presents an opportunity for disclosure, learning and prevention of errors. Competing interests: None declared