Abstract
Objective
This study assessed the implementation of psychiatry morbidity and mortality rounds (M&Ms) on the clinical and educational practice in a children’s hospital.
Methods
Attendees to monthly M&Ms between July 2005 and May 2007 included staff and trainees from psychiatry, psychology, nursing, and social work. Cases were selected based on a priori risk criteria and each rated on the hospital’s four-level risk management scale. M&Ms were reviewed for recurrent patterns that contributed to adverse patient care. Attendees completed a survey at the end of each year, evaluating the educational value of the rounds.
Results
Possible opportunities for patient care improvement were found in 80% of the cases and fell into four overlapping areas: diagnostic/formulation errors, communication problems, system-based problems, and class/culture misunderstandings. Identifying these problems led to corrective actions and positive changes in patient care.
Conclusion
M&Ms appear to be a potentially productive venue for self-appraisal and case review to aid psychiatry programs in patient safety efforts and clinician education.
Similar content being viewed by others
References
Kohn KT, Corrigan JM, Donaldson MS (eds): To Err is Human: Building a Safer Health System. Washington, DC, Academy Press, 1999
Orlander JD, Fincke BG: Morbidity and mortality conference: a survey of academic internal medicine departments. J Gen Intern Med 2003; 18: 656–658
Stewart M: Core Competencies: Accreditation Council for Graduate Medical Education 2008. Available at www.acgme.org/acWebsite/home/home.asp
Gordon LA: Can Cedars-Sinai’s “M+M matrix” save surgical education? Bull Am Coll Surg 2004; 89: 16–20
Kravet SJ, Howell E, Wright SM: Morbidity and mortality conference, grand rounds, and the ACGME’s core competencies. J Gen Intern Med 2006; 21: 1192–1194
Biddle C, Oaster TR: Investigating the nature of the morbidity and mortality conference. Acad Med 1990; 65: 420
Orlander JD, Barber TW, Fincke BG: The morbidity and mortality conference: the delicate nature of learning from error. Acad Med 2002; 77: 1001–1006
Murayama KM, Derossis AM, DaRosa DA, et al: A critical evaluation of the morbidity and mortality conference. Am J Surg 2002; 183: 246–250
Pierluissi E, Fischer MA, Campbell AR, et al: Discussion of medical errors in morbidity and mortality conferences. JAMA 2003; 290: 2838–2842
Leape LL, Berwick DM: Five years after To Err Is Human: what have we learned? JAMA 2005; 293: 2384–2390
Kinzie JD, Maricle RA, Bloom JD, et al: Improving quality assurance through psychiatric mortality and morbidity conferences in a university hospital. Hosp Community Psychiatry 1992; 43: 470–474
Coleman RL, Hunter DE: Contemporary quality management in mental health. Am J Med Qual 1995; 10: 120–126
Fauman MA: Quality assurance monitoring in psychiatry. Am J Psychiatry 1989; 146: 1121–1130
Balla M, Knothe B, Lancaster J, et al: Group peer review in psychiatry: the relationship to quality improvement and quality care. Aust N Z J Psychiatry 1996; 30: 653–659
Berwick DM, Leape LL: Reducing errors in medicine. Qual Health Care 1999; 8: 145–146
Gillig PM, Barr A: A model for multidisciplinary peer review and supervision of behavioral health clinicians. Community Ment Health J: 1999; 35: 361–365
Goh J, Singh B: The national health performance framework: an evaluation model for use by psychiatrists. Australas Psychiatry 2005; 13: 111–115
Hollanda J: A role for morbidity and mortality conferences in psychiatry. Australas Psychiatry 2007; 15: 338–342
Patel M, Hardy DW, Chand R: Peer review for residents. Acad Psychiatry 2005; 29: 490–494
Author information
Authors and Affiliations
Corresponding author
Additional information
At the time of submission, the authors declared no competing interests.
Rights and permissions
About this article
Cite this article
Goldman, S., Demaso, D.R. & Kemler, B. Psychiatry Morbidity and Mortality Rounds: Implementation and Impact. Acad Psychiatry 33, 383–388 (2009). https://doi.org/10.1176/appi.ap.33.5.383
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1176/appi.ap.33.5.383