Author: Dominick Shelton
LeBron was in the last few months of his emergency medicine (EM) residency and was tasked with presenting morbidity and mortality (M&M) rounds during an EM rotation. Between clinical shifts and incessant studying for his exam, he carved out time to prepare the rounds. Although he had been a participant in many M&M rounds, he realized that he had never presented at one. He didn’t have a good case to present and wondered where to find one. He also wasn’t sure what approach to take in presenting a case. He wondered if he should present a review of a topic related to the case? He didn’t want to blame anyone for a bad outcome of a case, but wasn’t certain how to maximize the learning for all.
M&M rounds are an integral component to developing an organizational culture of safety that is operationalized on a departmental level. Although there are still remnants of a shame and blame approach to addressing error in health care, M&M rounds have undergone a deliberate shift towards a system-based approach to identify system gaps and cognitive biases. Learning from adverse events, errors and near-misses is an example of team-based learning in health care that contributes to a culture of safety.(1)
Given the multitude of processes at play that enable any single patient in the emergency department (ED) to receive the right care, it is inevitable that errors will occur, some of which will reach the patient. Every ED should have M&M rounds to bring to light system failures and to identify opportunities to make improvements. The question should be how often an ED has M&M rounds, not whether they are held.
The goals of M&M rounds should be clear to all participants:
To learn from adverse events and near misses
To advance patient safety and quality improvement
To educate all healthcare providers and staff
There are several frameworks for the M&M review process to ensure consistency and achieving intended goals. One such framework that was developed by EM colleagues and is well designed is the Ottawa M&M Model (OM3).
OM3 provides recommendations on:
Case selection
Case analysis
How to present and facilitate rounds
Methods of disseminating lessons learned
Follow up of action items(2)
Although any clinician can present M&M rounds, it is helpful for the presenter to have some appreciation of a framework for M&M reviews. Consider designating a M&M leader who coordinates and facilitates the rounds.
Cases can be identified from the following sources:
Frontline providers’ clinical cases
Hospital safety reporting system
Departmental leadership
Patient complaints
ED return visits
Deaths in ED
It is generally accepted that M&M cases should have all three of the following components:
Adverse outcome(s), including near misses
Be preventable
Lessons to be learned about cognitive or system issues2
Although M&M rounds traditionally focussed on poor outcomes, there is much value in presenting cases with errors resulting in near-misses or minor impact to patients. These cases are frequent and addressing them with retrospective case analysis is a proactive approach to prevent potential future harm.(3)
In order to balance the focus on system issues or cognitive biases that contribute to an adverse event, some EDs are now combining Amazing and Awesome (A&A) rounds with M&M rounds to illustrate and celebrate when the system and provider work well to result in a positive outcome for a patient; whether it be making a difficult diagnosis or correct management.
Analyze cases to determine if any of the following apply:
System Issue/Cognitive Bias | Example |
Patient Factor | Patient’s inability to speak English |
Care Team Factor | The respiratory therapist was unavailable, since he was managing another acutely ill patient in the ICU |
Task Factor | Patient was assessed during system upgrade, so electronic medical records were unavailable |
Equipment Factor | Equipment use was not intuitive |
Work Environment Factor | Crowded ED with no available examination room to examine patient |
Organizational Factor | Frequent work-around a documented policy |
Cognitive Bias | Premature closure, anchoring |
M&M Round Case Analysis (source: https://www.patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/Documents/Module%2016%20-%20Canadian%20Incident%20Analysis%20Framework.pdf)
Analysis of M&M cases provides an opportunity to identify and discuss system problems that contribute to medical error. It allows a discussion of unique aspects of the ED work environment that predispose to error (i.e. frequent interruptions, incomplete patient information, inadequate communication, pressures resulting from high volumes and long waits).5
Ideally, M&M rounds should be attended by the interprofessional team. Realizing that emergency nurses do not regularly attend rounds, one strategy to increase their attendance is to invite a nurse to present a case. Emergency nursing leadership (managers and educators) should be expected to attend, in light of their potential role in the follow-up improvement process. Consider inviting consultants that were involved in the follow-up care or who you believe may provide meaningful contribution to the discussion.
M&M rounds should begin with a list of objectives and goals and a reminder of the ground rules. Well intended colleagues may breech the rules and need reminding occasionally.
M&M Round Rules:
No individual blaming
If the provider of care in the case does not self-identify, then do not disclose the name of the provider if privy to such information
This is a psychologically safe space
No recording or minutes will be taken, other than lessons learned and action items
During the presentation, if possible build the case to simulate the sequence of knowledge acquisition and events. Embed questions into your presentation to encourage audience participation. Provide enough information for your colleagues to generate a differential diagnosis. Ask the audience to commit to a course of action at decision points, including investigation, treatments and disposition.(5) This approach encourages empathy for the provider rather than judgement. Try to incorporate some educational points and evidence-based literature into the case discussion. In doing so, the audience can not only learn from challenges of the case and witness the impetus for making improvements, but also feel they have gained new knowledge.
Try to engage the audience in the error analysis discussion and prevention strategies. As a facilitator, be sure to name the cognitive and or system issues that contributed to the outcome. Although the facilitator will come to the rounds prepared with some lessons learned and potential action items, an engaged and invested audience will hopefully identify them through meaningful discussion. It is important that recommendations for improvements are not targeted at the sharp end of clinical error (point of care by provider). Instead, try to steer the conversation toward the blunt end (processes) that will have greater impact at preventing future harm and facilitate providers to make the right decision for patients.
A summary of lessons learned from cases should be circulated to department members, so that those absent may also learn. These lessons learned should be archived for future reference and for the benefit of new hires. An established process needs to be in place to delegate the action items to a leader (medical or nursing) or a committee (operations or quality) to further review and operationalize the recommended interventions.(6) M&M&I rounds is sometimes used as an alternate term to highlight the improvement component of the process to prevent future harm.
Paramount to the effectiveness of M&M rounds is the creation of a psychologically safe space to discuss thought processes and admit vulnerabilities. Despite an attempt to do so, not everyone will feel comfortable to disclose being care provider for the case. Ideally the provider will either present the case or as a member of the audience participate in discussion. Regardless, the role of the provider must be respected, whether as a presenter, audience participant or anonymous listener. Depending on details of the case, many factors will contribute to the perception of psychological safety, despite best intentions (e.g., one’s seniority in the department or fear of litigation). The rounds facilitator should also be attuned to the possible need to debrief individually with the provider after rounds.(6)
M&M rounds have come a long way since they were introduced a century ago. They have evolved as medicine has evolved to focus on patient safety. Learning from adverse events and near misses fosters a culture of safety, a requirement to prevent patient harm. Use of M&M case analysis frameworks enables a focus on system issues and cognitive biases, leading to potential improvements, rather than sharp judgement of colleagues.
Back to the Case
LeBron spoke to the Medical Director for Quality & Safety in the ED he was working in. The physician selected a case for him that was recently identified from a safety report. LeBron was informed about OM3 and used it to prepare his case presentation. He was commended by the residency site coordinator for an excellent case presentation that generated good discussion and for bringing forward a system issue for improvement that had been ignored for too long in the ED.
Given the value and importance of M&M rounds, it is important that residents and medical trainees participate in the process during their training. By the end of residency, all trainees will invariably have witnessed M&M rounds as an audience member. However, how many graduating emergency medicine residents can say that they have participated in an M&M case analysis using a framework to identify cognitive and system issues? In this era of competency-based training, residency programs should be encouraged to incorporate M&M case presentations as a requirement for senior emergency medicine residents.
Senior Editor: Lucas Chartier
Copyedited by: Sabrina Campbell
References:
Batthish M. Organizational Learning in the Morbidity and Mortality Rounds. Dalla Lana School of Public Health. Published 2015. https://ihpme.utoronto.ca/document/organizational-learning-in-the-morbidity-and-mortality-rounds/
Calder LA, Kwok ESH, Adam Cwinn A, et al. Enhancing the Quality of Morbidity and Mortality Rounds: The Ottawa M&M Model. Yarris L, ed. Acad Emerg Med. Published online March 2014:314-321. doi:10.1111/acem.12330
Chathampally Y, Cooper B, Wood D, Tudor G, Gottlieb M. Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors. WestJEM. Published online October 6, 2020. doi:10.5811/westjem.2020.7.47583
Emanuel L, Taylor L, Hain A, et al. Canadian Incident Analysis Framework. Patient Safety Institute. Published 2014. https://www.patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/Documents/Module%2016%20-%20Canadian%20Incident%20Analysis%20Framework.pdf
Houry D, Gibbs M. Preparing a Morbidity and Mortablity Conference. Soc Acad Emerg Med Newsletter. https://www.saem.org/docs/default-source/saem-documents/residents/preparing-a-morbidity-and-mortality-conference.pdf?sfvrsn=a4070b2b_4
McCool T, Chan T, Mondoux S, et al. The M&M Shame Game. Academic Life in Emergency Medicine. Published 2017. https://www.aliem.com/wp-content/uploads/2017/12/Case-of-the-MM-Shame-Game.pdf