Table 1
Patient and Admission Characteristics.
| PATIENT AND ADMISSION CHARACTERISTICS | Number of cases (%) (N = 27) |
|---|---|
| Female | 14 (52) |
| Male | 13 (48) |
| Median age | 68 |
| HIV status | |
| Positive | 10 (37) |
| Negative | 11 (41) |
| Unknown | 6 (22) |
| Day of admission | |
| Monday | 8 (30) |
| Tuesday | 4 (15) |
| Wednesday | 4 (15) |
| Thursday | 1 (4) |
| Friday | 4 (15) |
| Saturday | 2 (7) |
| Sunday | 4 (15) |
| Seen by ward doctor prior to death | |
| Yes | 19 (70) |
| No | 8 (30) |
Table 2
Findings at Presentation.
| Presenting Sign or Symptom | Number of cases (%) (N = 27) |
|---|---|
| Respiratory distress | 20 (74) |
| Altered mental status | 17 (63) |
| Hypotension | 11 (41) |
| Tachycardia | 9 (33) |
| Vomiting and/or diarrhea | 5 (19) |
| Fever | 5 (19) |
| Chest pain | 4 (15) |
| New onset hemiparesis | 2 (7) |
| Collapse | 1 (4) |
| Hypertension | 1 (4) |
| Jaundice | 1 (4) |
| Seizure | 1 (4) |
| Night sweats | 1 (4) |
| Dizziness | 1 (4) |
| Hypothermia | 1 (4) |
| Headache | 1 (4) |
| Renal failure | 5 (19) |
| Hypokalemia | 3 (11) |
| Hypoglycemia | 3 (11) |
| Hyperkalemia | 3 (11) |
| Myocardial ischemia on ECG | 1 (4) |
| Hyperglycemia | 1 (4) |
| Severe anemia | 1 (4) |
| Hyponatremia | 1 (4) |
Table 3
Probable Causes of Death.
| Probable Cause of Death | Number of cases (%) (N = 27) |
|---|---|
| Septic shock: | 10 (37) |
| Pulmonary TB (presumed or known) | |
| Septic shock: | 6 (22) |
| Pulmonary, presumed non-TB pathogen | |
| Septic shock: | 1 (4) |
| Extrapulmonary TB (presumed) | |
| Septic shock: | 3 (11) |
| Unclear source | |
| Pulmonary edema | 4 (15) |
| Cardiac shock | 2 (7) |
| Aspiration pneumonia | 2 (7) |
| Meningoencephalitis | 2 (7) |
| Lymphoma | 2 (7) |
| Hyperkalemia/renal failure | 2 (7) |
| Diabetic ketoacidosis | 1 (4) |
| Liver failure | 1 (4) |
Table 4
Care Management Problems.
| Care Management Problems | Number of cases (%) N = 27 |
|---|---|
| Delay in administration of antibiotics | 15 (56%) |
| Inappropriate fluid management | 15 (56%) |
| Deficient coordination of care | 15 (56%) |
| Inadequate management of hypoxia | 13 (48%) |
| Lack of infectious workup | 11 (41%) |
| Imaging studies not done | 11 (41%) |
| Unavailability of laboratory test results | 11 (41%) |
| Inadequate follow-up of laboratory test results | 10 (37%) |
| Inadequate patient monitoring | 9 (33%) |
| Inadequate management of electrolytes | 6 (22%) |
| Inappropriate medication management | 4 (15%) |
| Delay in MD evaluation | 3 (11%) |
| Arrhythmia not addressed | 3 (11%) |
| Lack of access to intensive care | 3 (11%) |
| Inadequate management of heart failure | 2 (7%) |
| Lack of recognition of cardiac ischemia | 2 (7%) |
| Delay in blood transfusion | 2 (7%) |
| Delay in lumbar puncture | 2 (7%) |
| Unavailability of necessary medication | 1 (4%) |
Figure 1
Sample Data Collection Study Template.
Table 5
Contributory Factors.
| Contributory factor | Number of cases (%) N = 27 |
|---|---|
| Knowledge and skills | 25 (93%) |
| Complexity of condition | 20 (74%) |
| Verbal and written communication | 18 (67%) |
| Maintenance and availability of equipment | 17 (63%) |
| Availability and use of protocols | 16 (59%) |
| Availability of test results | 15 (56%) |
| Staffing levels | 13 (48%) |
| Financial resources and constraints | 11 (41%) |
| Failure of team leadership | 8 (30%) |
| Policy standards and goals | 6 (22%) |
| Patterns in workload/shift | 3 (11%) |
| Administrative and managerial support | 3 (11%) |
| Safety culture and priorities | 2 (7%) |
| Willingness to seek help | 1 (4%) |
| Patient personality and social factors | 1 (4%) |