A morbidity and mortality (M&M) conference is a time-honored educational format in surgery and medicine to review bad patient outcomes and learn from mistakes made. However, despite the value of learning together as peers from difficult cases with unexpected outcomes, most psychiatric departments in the United States do not have an M&M conference. Several years ago, the department of psychiatry at Massachusetts's general hospital in Boston began a monthly M&M conference.

Describe our department's experience with the M&M format as an educational vehicle to teach patient safety and improve care in an increasingly complex care environment.

Introduce the M&M format that we have developed at our department and obstacles encountered.

We reviewed the content of our four years of M&M conferences; the feedback received from participants after each conference; and changes introduced to improve the conference.

Our department has successfully implemented and sustained a monthly psychiatric M&M conference that is well attended and valued. A critical decision was mandatory involvement of residents to prepare cases in conjunction with a dedicated faculty member. A structured presentation using a root cause analysis framework to guide the discussion in order to harness the wisdom of the group allows for a more comprehensive understanding of factors leading to bad outcomes, including systems-based problems.

A psychiatric M&M conference can teach individual clinicians about patient safety. Developing a departmental mechanism to apply lessons learned in the conference to improve hospital systems is the next task.