We report a retrospective study of 59 patients for whom our university hospital nursing service had required the use of lay sitters because of the need for constant observation. Of 54 charts examined, 28 noted a need for psychiatric consultation, mostly because of delirious states. Quality of care deficits discerned included (1) inadequate pharmacotherapy of alcoholic and nonalcoholic delirium, (2) inadequate search for treatable causes of delirium (thyroid, B12, and folate deficiencies), (3) insufficient awareness of persistent cognitive deficits, which influence the patient's ability to care for himself or give informed consent. The knowledge and skills deficits we found are not unique to this hospital and reflect the failure of most graduate programs to reinforce basic psychiatric teaching. The quality of care issues indicate that more serious consideration should be given to providing necessary psychiatric training.