Psychiatry morbidity and mortality rounds: implementation and impact.
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.


CONCLUSIONS
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.
Goldman
Stuart
S
Psychiatry at Children's Hospital Boston, 300 Longwood Ave., Boston, MA 02115, USA. goldman@childrens.harvard.edu
Demaso
David R
DR
Kemler
Beth
B
D000293:Adolescent; D001900:Boston; D002423:Cause of Death; D002648:Child; D002983:Clinical Competence; D003299:Cooperative Behavior; D003479:Curriculum; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D001523:Mental Disorders / Q000401:mortality / Q000628:therapy*; D010348:Patient Care Team; D010380:Peer Review; D011570:Psychiatry / Q000193:education*; D011787:Quality of Health Care / Q000458:organization & administration*; D012308:Risk Management; D056164:Teaching Rounds / Q000458:organization & administration*