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Re: Mortality and Morbidity Review

The process referred to by Dr. Greene is called a Mortality and Morbidity Conference at my institution.  It is an anonymous process in which interesting cases with unfortunate (not necessarily misadventures) are reviewed with intent to educate.  Our conference is restricted to physicians and no physician or patient indentifiers of any case are used.  No immunity to discovery is granted by this process but since anonymity exists and no records are kept ... any discovery would be difficult.

A separate process known as institutional peer-review does have qualified immunity to discovery (at least in Louisiana) to promote continous quality improvement.  I would have to discuss with my attorney the restrictions before posting here.  With peer-review, selected cases are methodically reviewed and critiqued.  Feedback is delivered in a generic response back to the individual(s) where merited.

I am not certain if any process has immunity in the case of "gross" negligence or other types of criminal conduct as that would constitue conspiracy to cover up a crime.  As the list may know, minor mistakes are part of any human endeavor and the medical response has (is) evolving to meet the need of quality impovement.  This response necessarily requires participation which is fostered by a process immune from legal discovery.  While our "internal review" process findings and recommendations might be protected, a formal outside (legal or state social service) investigation would not.

>From: "Walter Fahr"
>Reply-To: CHILD-MALTREATMENT-RESEARCH-L@cornell.edu
>To: Child Maltreatment Researchers
>Subject: Re: Mortality and Morbidity Review
>Date: Wed, 17 Jan 2001 16:55:26 -0600
>
>I think the question has some interesting ramifications. Our agency has an internal review process for child fatalities. The purpose of the internal review is to learn more about child deaths to prevent their future occurrence. However, as far as a true equivalent of a Mortality and Morbidity review, I do not believe that CPS workers are afforded the same immunity from adverse action as is extended to physicians when an internal review is conducted by a CPS agency. If gross negligence were discovered during an internal review of a child fatality, it is very likely that administrative action against an employee would be initiated. In some cases, criminal charges have even been levied by a prosecutor.
>
>The next level of fatality review would be a local child death review committee followed by a state level committee. These multidisciplinary review committees are much broader in scope and have as their function to make recommendations to improve the system.
>
>If you need a copy of specific agency policy on internal reviews you can email me at the address below.
>
>
>Walter Fahr
>Program Manager-CPS
>State of Louisiana
>
>fswalter@ocs.dss.state.la.us
>
> >>> bfgreene@siu.edu 01/17/01 11:10AM >>>
>Greetings,
>
>In medical circles there is a process for reviewing cases that go
>awry, sometimes with catastrophic results. That process is sometimes
>referred to as Morbidity and Mortality reviews and is conducted in
>confidence in order to learn what, if anything, might be done
>differently in the future.
>
>Can anyone direct me to guidelines for conducting similar reviews in
>child welfare for cases that involve either tragic (e.g., death,
>injury) or unsatisfactory outcomes (e.g., failure to achieve goals).
>I realize there may be an assortment of mechanisms and processes to
>exercise hindsight and oversight. I'm interested in published (or
>printed) guidelines for conducting such reviews internal to a child
>welfare agency or system.
>
>Thanks.
>--
>Brandon F. Greene, Ph.D.
>Professor, Behavior Analysis & Therapy
>Coordinator, Project 12-Ways
>Southern Illinois University
>Carbondale, IL 62901
>Ph: (618)453-2434
>Fax: (618)453-2450
>EMail: bfgreene@siu.edu
>
>

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From ???@??? Thu May 25 12:53:05 2000 Status: U Return-Path: Received: from elist01.mail.cornell.edu (ELIST01.MAIL.CORNELL.EDU [132.236.56.28]) by postoffice.mail.cornell.edu (8.9.3/8.9.3) with ESMTP id MAA06022; Thu, 25 May 2000 12:46:25 -0400 (EDT) Received: (from daemon@localhost) by elist01.mail.cornell.edu (8.9.3/8.9.3) id MAA09933; Thu, 25 May 2000 12:46:23 -0400 (EDT) Received: from elist01.mail.cornell.edu (localhost [127.0.0.1]) by elist01.mail.cornell.edu (8.9.3/8.9.3) with SMTP id LAA08492; Thu, 25 May 2000 11:54:44 -0400 (EDT) Received: from router2.mail.cornell.edu (ROUTER2.MAIL.CORNELL.EDU [132.236.56.16]) by elist01.mail.cornell.edu (8.9.3/8.9.3) with ESMTP id JAA01531 for ; Thu, 25 May 2000 09:05:46 -0400 (EDT) Received: (from daemon@localhost) by router2.mail.cornell.edu (8.9.3/8.9.3) id JAA28377 for CHILD-MALTREATMENT-RESEARCH-L@elist01.mail.cornell.edu; Thu, 25 May 2000 09:05:45 -0400 (EDT) Received: from kki.kennedykrieger.org (kki.kennedykrieger.org [207.123.182.11]) by router2.mail.cornell.edu (8.9.3/8.9.3) with SMTP id JAA28361 for ; Thu, 25 May 2000 09:05:44 -0400 (EDT) Received: from GATEWAYS-Message_Server by kki.kennedykrieger.org with Novell_GroupWise; Thu, 25 May 2000 09:05:34 -0400 Message-Id: X-Mailer: Novell GroupWise Internet Agent 5.5.3.1 Date: Thu, 25 May 2000 09:07:00 -0400 X-PH: V4.1@router2.mail.cornell.edu (Cornell Modified) X-PH: V4.1@elist01.mail.cornell.edu (Cornell Modified) From: "Scott Cangelosi" To: Child Maltreatment Researchers Subject: Re: severity of abuse -Reply Mime-Version: 1.0 Content-Type: text/plain; charset=US-ASCII Content-Disposition: inline Content-Transfer-Encoding: 8bit X-MIME-Autoconverted: from quoted-printable to 8bit by elist01.mail.cornell.edu id JAA01532 Message-Tag: 687 Reply-To: CHILD-MALTREATMENT-RESEARCH-L@cornell.edu Sender: owner-CHILD-MALTREATMENT-RESEARCH-L@cornell.edu X-Listprocessor-Version: 8.2.09.cu01/000107/15:22 -- ListProc(tm) by CREN Your latest input to the discussion of ADHD etiology is intriguing! I am wondering if the research accounts for the premise that early childhood attachment experiences can influence the actual development of the brain? Siegel writes, "'Developmental overpruning' refers to the toxic effect of overwhelming stress on the young brain: The release of stress hormones leads to excessive death of neurons in the crucial pathways involving the neocortex and limbic system-the areas responsible for emotional regulation...The fact is that neither genetics nor environmental theories have led to a fundamental understanding of the etiologies of the vast majority of psychiatric disorders. If we have learned anything from recent studies, it is that a delicate interplay exists between nature and nurture." I have taken this to mean that the mere presence of differences in the brain functioning of control subjects as opposed to ADHD subjects does not rule out that environmental factors may cause (or at least interact with biological vulnerabilities to cause) psychiatric disorders. >>> jcrowley@NMSU.Edu 05/24/00 12:25pm >>> D > What an interesting question; Are children that are abused more likely to > have a diagnosis of ADHD or are they more likely to be abused because > they have ADHD? > Yes to both. I've been researching the links between ADHD and delinquent behavior with a colleague. So far, it's just a literature review, but we have a few observations relevant to this discussion. Most of the people doing research on ADHD per se have concluded that its origins are biological, involving at least two brain structures, the basal ganglia and the frontal lobes. These structures affect what are called the executive functions of the brain--those skills associated with planning and carrying out a complex course of actions. For most children, ADHD seems to be organic rather than a reaction to parenting. This finding is both frustrating and relieving for parents of ADHD children. Terrie Moffitt in some of her early longitudinal work noted that the children who continued committing delinquent acts after most of their age-mates had stopped were characterized by a combination of ADHD and poor parenting. The parenting practices are those associated with oppositional defiant disorder and with conduct disorder--e.g., parenting that alternates between being uninvolved and being harsh and demanding. Children who show the types of hyperactivity and inattentiveness associated with ADHD seem to be at risk of this type of parenting. It may be that some parents who would be adequate for an easy going child may be unable to meet the demands of children with special needs--ADHD, developmental delays, etc. Finally, Bruce Perry's work on the neurological impacts of abuse shows differences in brain organization which could produce behaviors that are associated with ADHD, among them hypervigilance and attention to threat cues which distract children from attending to other aspects of the classroom. So--the sum of these observations suggests that: 1. Trauma can produce behaviors that look like ADHD. 2. ADHD children are at risk of being abused by their parents. 3. The combination of ADHD and abuse is a formula for social disaster. If an ADHD child has been in a home that is inadequate, the foster parents will have a greater challenge than if they were dealing with either just ADHD or just abuse. The effects seem to be interactive, not merely additive. BTW--My co-author and I have wondered if there would be a publishing outlet for this work. Any suggestions? Jody Crowley Joan (Jody) Crowley Assistant Professor Department of Criminal Justice New Mexico State University Box 30001, Dept 3487 Las Cruces, NM 88003-0001 505-646-5376