• Stuart Goldman, David R Demaso, and Beth Kemler.
• Psychiatry at Children's Hospital Boston, 300 Longwood Ave., Boston, MA 02115, USA. goldman@childrens.harvard.edu
• Acad Psychiatry. 2009 Sep 1; 33 (5): 383-8.

ObjectiveThis study assessed the implementation of psychiatry morbidity and mortality rounds (M&Ms) on the clinical and educational practice in a children's hospital.MethodsAttendees 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.ResultsPossible 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.ConclusionM&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.

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