Patient safety is a huge issue, and one that is overwhelming to address as a “single” solvable problem. One component that is clearly missing from our emergency department is the organized approach to examining adverse events: the (historic) Morbidity and Mortality Rounds. I think we can all agree that we are not interested in the rounds of our distant (surgical) memories. What would be valuable, and indeed likely some of the best learning experiences we can attend, would be the safety and support of examining cases with less-than-ideal outcomes using a systems-based approach to identify areas for change and improvement…the KEA “Best Practices Rounds.” While there is parallel work being done at other levels (ie city level, resident level), there is a need and role for doing our own departmental rounds, with our work environment, and our people.