Web-based Morbidity and Mortality (M&M) Rounds

For the last several years, the AHRQ has been offering a forum for sharing and discussing issues of patient safety and healthcare quality, web M&M: Morbidity and Mortality Rounds on the Web.

The site includes de-identified cases of medical errors and other safety and quality issues, with accompanying expert commentary on what happened and how the problem might be avoided in the future. There are also forums for discussing each case.

The cases are drawn from all areas of health care and are always interesting, also great for learning more about different areas of medicine. One of the summer cases is informatics related and focuses on a medical error associated with use of an electronic medical record, Copy and Paste, with commentary by William Hersh. His take-home points from this case:

• Copying and pasting of patient information has probably been occurring since the beginning of recorded medical information.
• EHRs make copying and pasting very easy.
• When copying and pasting is done, the physician should be careful to attribute the source and to check that the information being pasted is not erroneous or out of date.
• The most effective means for insuring medical plans are carried out is through the use of clinical decision support tools, and such tools are made easier and more acceptable to use when orders are bundled in sets.

The site also includes tutorials on issues related to Spotlight Cases like this one on resuscitation errors, with CME/CEU credit provided, and transcripts of interviews and expert perspectives on safety and quality issues.