Measures

Failure mode

Consequence

Contributory factor

・ Recognition of high risk Mothers

・ Consultation and lab test request

・ Referral of high risk mothers to Higher Levels of care

・ Provision of appropriate care for high risk patients

・ Recognition of danger signs and possibilities of transformation of low risk patients to high risk

・ Provision of appropriate post partum care

・ Follow up especially for high risks up to 42 days

・ Inability to screen and recognize risks and failure to deliver adequate needed care

・ Inaccessibility of prenatal care file

・ Reluctance of high risk mothers for going to higher level of care

・ maternal/neonatal morbidity and mortality

・ Inadequate /inefficient Staff training programs

・ Poor audit and feedback

・ Lack of supporting referral system

・ Lack of skills and information

・ Lack of coordination in different levels of Care

・ Lack of follow up system

・ Poverty

・ Poor insurance coverage

・ Socio-cultural problems