Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years.

Study Objective: We describe cases referred for physician review because of concern about quality of patient care and identify factors that contributed to patient care management problems.

Methods: We performed a retrospective review of 636 cases investigated by an emergency department physician review committee at an urban public teaching hospital over a 15-year period. At referral, cases were initially investigated and analyzed, and specific patient care management problems were noted.