Peer review is a valuable way to review the care that is provided by physicians and nurses. We do not expect that people perform perfectly, but we do sometimes need to determine if care is adequate. If, over time providers appear to have an unusual number of cases in which care is considered to not meet the standard of care, a further review can be done. In some cases, further review finds that a provider is seeing a large number of very complicated patients and so an increase rate of outcomes that are not perfect, might be acceptable. In other instances, the care concerns suggest that a provider may need a more focused review of their practice. If this focused review shows no further concerns we move on. If there are concerns that are found, then decisions may have to be made as to whether that individual should have their privileges should be restricted or terminated.
This process is not perfect but it does offer a structured way to determine if a provider may have a problem in their practice. Yet, there are other instances in which it is very clear that a mistake was made. If a provider causes a complication while doing a procedure or a radiologist misses a very obvious bleed in the head, it is clear that this is a mistake. It is not the standard of care to miss an obvious finding on a head CT or to cause a complication during a procedure. But if it is obvious that this is not the standard of care, then isn’t peer review just rubbing salt in a wound? Providers already view peer review as punitive despite our best efforts to say it is about quality not punishment.
So how should we review these types of procedural errors and complications?
Procedural mistakes should be reviewed, but perhaps they should not be reviewed in the same way as diagnostic errors. A retained guidewire, wrong-site procedure, retained surgical item, or line complication caused by skipped safety steps is usually best handled as a patient-safety event with a professional-practice accountability component, not as a conventional “was the doctor’s judgment reasonable?” case alone. There are a variety of things to be considered – was the case an emergency, were there circumstances that made the procedure more difficult than normal, were appropriate precautions taken in trying to do the procedure.
The key distinction is this: diagnostic errors often involve probabilistic reasoning under uncertainty, whereas many procedural errors involve execution of a known, bounded task in which the safety process is expected to prevent a specific failure mode. Further, every procedure does have certain risks of complications, and this must be taken into account. Where appropriate steps taken to prevent this known complication? That difference should change the review method, the questions asked, and the corrective actions.
Final Thoughts
Consider use of a two-track review model when considering the care the providers have delivered:
- Patient Safety / RCA or apparent-cause review for the event itself: What system, equipment, team, training, workflow, supervision, or forcing-function failure allowed the event?
- Focused professional practice review for the individual clinician: Was this a human error, at-risk behavior, reckless behavior, competence gap, supervision failure, impairment issue, or pattern of repeated unsafe practice?
This approach aligns with just-culture principles, which distinguish human error, at-risk behavior, and reckless behavior and recommend different organizational responses for each. AHRQ’s safety-culture primer similarly emphasizes that just culture addresses system issues while maintaining accountability, especially for reckless behavior.