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Duration: 8:20

This podcast is an episode of Patient Safety Updates. You can find other episodes and subscribe using the links to the left.


Morbidity and Mortality rounds, or M&Ms, are a classic hospital technique for learning from bad patient outcomes. In some of the healthcare networks at Harvard, M&Ms are picking up steam at ambulatory sites. And for good reason. Medical professional liability claims with the highest incurred payout in the Harvard medical system during 2012 came from the ambulatory clinical setting.

The number of claims is higher too: 49 percent of medical malpractice claims arose in out-patient care, excluding the E-R, versus 42 percent that were in-patient. This trend is now the focus of intense activity for patient safety staff and administrators. The biggest challenge is designing risk reduction efforts for ambulatory sites when traditional patient safety/risk management has been largely focused on in-patients. Elizabeth Allen is an ambulatory risk safety nurse at Massachusetts General Hospital. Allen is using a patient safety grant to produce M&M rounds for clinics and medical groups affiliated with the institution.

“There is a tremendous hunger and interest to really even understand quality and safety work in the ambulatory setting.”

The grant came through CRICO. CRICO is a group of companies owned by and serving the Harvard medical community that provides insurance coverage, claims management, and patient safety resources to its members. Ten sites share a three-year, $5 million initiative. Allen notes that data associated with malpractice claims point to specific, fixable flaws in out-patient care processes. And it explains why CRICO’s board members, many of whom run Harvard teaching hospitals, are directing funds to help plug those holes.

“I think that there are certain categories of cases that heighten concern for people. One would be anything where there is a delay in diagnosis, any issue that has to do with a delay in notification to a patient about an important clinical finding. Also issues that relate to both referral management or test result management. As I mentioned, those arenas are rich for discussions of systems and of communication patterns. And I think there are certain medication areas that carry more high risk.”

Blair Fosburgh is medical director for the CRICO ambulatory risk management grant at Mass General and a primary care physician. Dr. Fosburgh says M&M rounds were a grant requirement, in order to help engage every-day providers fairly quickly.

“It provides an opportunity for people to discuss cases where things either didn’t go well or where they almost didn’t go well. In medicine we often don’t take the time to really discuss those things and try to figure out systems issues to try to prevent things like this.”

According to Dr. Fosburgh, M&Ms provide two key values to clinicians:

  1. understanding how things happen
  2. understanding—even participating in—the institutional response to fix problems

“The more educational part is just walking through the process of really breaking down what happened when something went wrong. You know, the old blame and shame culture is that it was an individual who was at fault, and sometimes individuals are at fault, but usually it’s because the system isn’t supporting them in the way that it could best. So you want to look for system solutions. That’s a way of thinking that is new to some people. So the rounds offer an opportunity to highlight that and make people more aware.”

Dr. Fosburgh says an institutional response to the problems identified in these rounds is essential to their success. Each M&M includes an interactive discussion of potential solutions to problems that attendees identify from the case. Future participation in the rounds may depend on whether the clinicians see results.

“You can come back to a future rounds and say ‘hey, remember when we talked about this before? We actually managed to change this, so hopefully that will make the system better for everybody going forward.’ As opposed to oftentimes in various venues, you’ll talk about how things aren’t right, but nothing ever happens, and that’s really frustrating to people.”

An example of a system improvement emerged from one of the M&M rounds involving medication management. Nurse Allen says that it was clear from the case discussion that anticoagulant therapy education needed beefing up.

“As a result of our advocacy, we were able to work collaboratively with the Anticoagulant Management Services here at Mass General and we developed a training module with them. That training module actually became a mandatory requirement for all prescribing providers as of the beginning of this year.”

CRICO statistics show that medication errors warrant a specific focus by the patient safety department. In the out-patient setting, medication-related allegations are the fourth most frequent, behind surgical treatment, medical treatment and the leading category: diagnosis. CRICO’s national division pools malpractice claims data from non-Harvard institutions across the country, which shows a similar break-down—and a national need to focus on diagnosis errors. A closer look at diagnosis-related claims in the Harvard system shows that more than half involve cancer. Dr. Fosburgh says that, by drilling into the contributing factors during M&M rounds, they can start reducing these cases.

“We had a case which was a delay in a communication of a test result, and it turned out that in our institution there was not active communication to providers about that particular test result. At many other Partners institutions there was active communication, meaning the provider was notified by e-mail or paged, as opposed to just the paper lab slip coming through. It was highlighted this test result didn’t require active notification in our institution and that was changed. That particular issue would not be able to happen again.”

Dr. Fosburgh says attendance has been strong and feedback is positive. M&Ms in the ambulatory setting have more of a multi-disciplinary feel with nurses, pharmacists, surgeons, psychiatrists, and primary care doctors sometimes attending a single case. Nurse Allen says this makes sense for cases connected to out-patient care. Cases are complex, and so is the system.

“There are so many people involved in the care of a patient in the ambulatory… I know that patients are touched by many, many clinicians by the inpatient setting, but the patient is in one location and the treaters come to the patient, whereas we have the patient traveling between specialists, primary care physicians, outpatient diagnostic settings, you know, multiple specialists on one case. So I would say that the number of people that can be involved in the care of one patient and then the communication challenges because of that.”

If there’s one thing that organizers need it’s more cases. They have scheduled quarterly rounds and had a number of cases in hand when the program started. Cases have come formally through safety reports to the Quality department, and directly from involved providers. As the culture becomes more open to discussing problem cases and near-misses, the hope is that physicians and staff will be even more attuned to the process flaws behind them—and their ability to fix them.

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About the series

Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.


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