Jonathan Matías Chejfec-Ciociano, Adrian Orozco Guridi, Gerardo Prieto Hurtado, Maryam Tabibzadeh, André van Zundert, Adrian W Gelb, Paul Barach
Catastrophic fungal, fatal meningitis outbreaks in Mexico arose from failures of governance, learning, oversight, culture, supply chains, and frontline practice-and prevention requires coordinated action across the entire sociotechnical system. By situating perioperative safety failures within the broader context of health-system governance, this study demonstrates the value of participatory systems inquiry for linking frontline clinician experiences to policy and organizational priorities. The findings provide a foundation for strategies to strengthen health planning, regulatory oversight, and organizational readiness in complex health systems.
OBJECTIVES: Unsafe anaesthesia practices in Mexico have contributed to repeated outbreaks of fatal fungal meningitis, exposing broader health system vulnerabilities. This study aimed to analyse how structural weaknesses in perioperative care, spanning governance, workforce, and institutional practices, reflect deep gaps in health planning, regulation, clinical oversight and hospital management.
METHODS: We applied a participatory, role-based systems mapping approach. A two-phase design method combined a survey to identify perceived system failures with structured, guided interprofessional, participatory reflection sessions. Participants from diverse professional groups refined key themes and assessed their impacts on patient safety, workforce practice, and institutional integrity.
RESULTS: Four core themes emerged: resource management and operational efficiency; quality control and safety standards; regulatory compliance and institutional integrity; and personnel commitment and professional conduct. Beyond resource and regulatory gaps, the findings highlighted weak institutions, fragmented communication, and improvised workarounds normalised across professional groups. These patterns underscore system-wide deficiencies in national policy and system strategy implementation, health workforce planning, operational management, and organizational accountability.
CONCLUSIONS: Catastrophic fungal, fatal meningitis outbreaks in Mexico arose from failures of governance, learning, oversight, culture, supply chains, and frontline practice-and prevention requires coordinated action across the entire sociotechnical system. By situating perioperative safety failures within the broader context of health-system governance, this study demonstrates the value of participatory systems inquiry for linking frontline clinician experiences to policy and organizational priorities. The findings provide a foundation for strategies to strengthen health planning, regulatory oversight, and organizational readiness in complex health systems.