In the post, Dr. Edmund Kwok presents the Ottawa Morbidity and Mortality Model (OM3), and provides users with an helpful guide on how to implement change to effectively improve M&M rounds at any institution.

OM3 Guide

In modern medicine, the concept of keeping track of adverse events and reviewing them in hopes of preventing similar errors in the future has been documented at least since the beginning of the 20th century.[1] The seminal work by the Anesthesia Mortality Committee in 1935 laid the foundations for M&M rounds as we know them today, and regular M&M activities have been engraved in medical education for decades.[2,3]

Despite a tremendous number of hours out of healthcare providers’ busy schedules dedicated to attending these rounds, they have been relatively ineffective in actually reducing preventable medical errors. Think back to your the most recent M&M rounds you’ve attended, and honestly ask yourself:

  • Was it clear the purpose of the rounds was to discuss ways to improve quality of care for the next patient?
  • Did I learn anything about patient safety?
  • Were the discussions focused on ways to prevent future errors, rather than medical/surgical nuances?
  • Was there a blame-free environment where all participants felt safe to openly discuss why errors happened?
  • Did you leave the rounds with a concrete understanding of next steps and actionable items?

If you didn’t answer “yes” to all of the above, you aren’t alone. Check out this editorial for a more detailed discussion around current inadequacies common in M&M rounds, and what the literature suggests for ways to improve.[4]

Towards a Structured Approach

A number of years ago, our Emergency Medicine group asked ourselves the same questions. Although we religiously held monthly M&M rounds where unusually challenging (and often uncommon and/or unpreventable) cases were awkwardly presented, too many times we left our rounds feeling like nothing was really going to change. We finally struck a working group to revamp our M&M rounds from the ground up, based on published literature and patient safety expert opinion. The result was the “Ottawa M&M Model”, or OM3, which was validated initially within our Department of Emergency Medicine and Division of Trauma Services, followed by a hospital-wide implementation across multiple specialties.[5,6]

Briefly, the OM3 framework revolves around the following key principles:

  • Not all cases are suitable for M&M discussion – some adverse outcomes are unpreventable. M&M time should focus on case where lessons can be learned.
  • Presenters need to have a structured approach to case analysis when prepping for M&M rounds, as well as a framework with which to present and guide discussions around quality improvement and patient safety. Most physicians and residents have limited training in these areas, yet are often thrust into the role of running M&M rounds without coaching.
  • M&M rounds are much more effective when they are multidisciplinary and inter-professional. Medicine today is practiced in a team-based approach, and all relevant team players need to be in the room for proper case discussion and potential solution design.
  • There must be a formal mechanism in place to actually effect changes, and to act on the items arising out of M&M rounds.

The OM3 has demonstrated success in improving not only our own M&M rounds over the years, but has had similar positive impact at different institutions around the world; they include hospitals in all provinces across Canada, as well as places like the Mayo Clinic in the United States, NHS in England, and King Abdulaziz Medical City in the Middle East.

But we are not done! We recognize that not only is there value in analyzing cases of bad outcomes, but that there is also potential for learning from cases where things went exceptionally well. The concept of having Amazing & Awesome rounds was published by one of our own emergency physicians.[7] Together, the OM3 collaborators have now designed a structured framework on how to present what we call “What Works” (W&W) rounds, focused on not only celebrating the great work we do, but to articulate why things went well and how it can be learned by others. Stay tuned for this new addition to the OM3!

How do I get started?

We have revised our OM3 materials from an initially research-based platform, to a much more user-friendly guide that can be picked up and implemented by anyone wishing to improve (or start!) their local M&M rounds. Click here for the OM3 guide, which summarizes all the key learnings we’ve gathered over the years. We have also been more than happy to visit local centers to help kick off their processes with grand rounds presentations, as well as teleconferences with local quality leads to provide guidance and advice.

Feel free to reach out to either Edmund Kwok or Lisa Calder if you have any questions!


  1. Mallon B. Ernest Amory Codman: The End Result of a Life in Medicine. Philadelphia, PA: WB Saunders; 2000
  2. Ruth HS. Anesthesia study commissions. JAMA 1945;127:514-517
  3. Accreditation Council for Graduate Medical Education. Essentials and information items. Graduate Medical Education Directory 1995-1996
  4. Kwok ESH. Inadequacy of current morbidity and mortality review activities: evolution of a time-honored tradition needed. Joint Commission Journal on Quality and Patient Safety 2017;43(1):3-4
  5. Calder LA, Kwok ES, Cwinn AA, Worthington J, Yelle JD, Waggott M, Frank JR. Enhancing the quality of morbidity & mortality rounds: the Ottawa M&M Model. Acad Emerg Med 2014; 21(3):314-321
  6. Kwok ES, Calder LA, Barlow-Krelina E, Mackie C, Seely AJ, Cwinn AA, Worthington JR, Frank JR. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf. 2016 Jun 29. pii: bmjqs-2016-005459. doi: 10.1136/bmjqs-2016-005459.
  7. Fischer LM. Amazing and awesome rounds. Ann Emerg Med. 2017 May. 69(5):655


  • Edmond Kwok

    Dr. Kwok is a staff Emergency Physician, director of quality improvement, assistant professor and clinical investigator at the Ottawa Hospital.

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