Mapping System Vulnerabilities in Anaesthesia Safety: A Role-Based Inquiry in Response to Fatal Fungal Meningitis...

Area of Science:

• Healthcare Management
• Patient Safety
• Public Health Policy

Background:

• Unsafe anesthesia practices in Mexico have led to fatal fungal meningitis outbreaks.
• These outbreaks highlight significant vulnerabilities within the broader health system.

Purpose of the Study:

• To analyze structural weaknesses in perioperative care, including governance, workforce, and institutional practices.
• To identify gaps in health planning, regulation, clinical oversight, and hospital management.

Main Methods:

• A participatory, role-based systems mapping approach was employed.
• A two-phase design combined surveys with interprofessional reflection sessions.
• Participants assessed impacts on patient safety, workforce, and institutional integrity.

Main Results:

• Four core themes emerged: resource management, quality control, regulatory compliance, and personnel conduct.
• Weak institutions, fragmented communication, and normalized workarounds were identified.
• System-wide deficiencies in policy implementation, workforce planning, and accountability were evident.

Conclusions:

• Fungal meningitis outbreaks resulted from failures in governance, learning, oversight, culture, supply chains, and practice.
• Prevention necessitates coordinated action across the sociotechnical system.
• Participatory systems inquiry can link frontline experiences to policy for strengthening health systems.