I want to continue the discussion about some of the problems with the typical peer review process used by healthcare systems to review care delivery by licensed providers. Let’s review the differences between diagnostic and procedural errors/mistakes.
A diagnostic error review usually asks:
“Given the information reasonably available at the time, was the diagnostic reasoning, differential diagnosis, testing strategy, follow-up plan, and communication consistent with accepted practice?”
That review must account for uncertainty. Many diagnostic decisions are made with incomplete information, evolving symptoms, misleading tests, atypical presentations, time pressure, and cognitive bias. The National Academies describes diagnosis as a complex, collaborative process involving clinical reasoning and information gathering, rather than a single isolated technical act.
A procedural mistake review asks:
“Was a known safety-critical procedure performed according to required technique, supervision, checklist, equipment, timeout, post-procedure verification, and counting/confirmation practices?”
An example case to consider is something like a retained guidewire from the placement of a central line. For those in healthcare, we know that this is something that should not happen. But there are instances that are emergencies in which the normal standards might need to be considered differently. So let’s consider a different approach.
For retained objects and retained guidewires, the event is usually more analogous to a high-reliability process failure than a difficult diagnostic judgment. AHRQ notes that occasions of retained surgical items are typically driven by ineffective practices, communication failures, complex work environments, and problematic systems or equipment, and that prevention should focus on system redesign rather than only correcting individual behavior.
So, it still may be appropriate for the clinician to go through a peer review process. But the review should not be framed simply as: “Doctor made a mistake; did the doctor meet standard of care?” That is too narrow of a question.
How we might categorize procedural events associated with errors?
Taking an incident of a retained guidewire after central line placement as an example, we might review the actions of the provider and try to determine which of the below categories most resemble the actions of the provider. This approach does not guarantee that everyone will agree but it does give a framework for people to discuss the case. It is also possible that people may feel that more than one category fits the case, particularly since there is often more than one action/decision point that the clinician faced.
| Category | Meaning | Peer review consequence |
| Unintentional human error despite reasonable practice | Clinician was trained, followed usual steps, no known shortcuts, rare slip/lapse occurred | Coaching, disclosure, patient-safety review, possible simulation refresh; usually not punitive |
| At-risk behavior | Clinician normalized unsafe shortcuts: no checklist, no assistant confirmation, no wire visualization, no post-procedure verification | Peer review finding may be appropriate; require remediation, proctoring, focused FPPE, behavior expectation |
| Reckless behavior | Conscious disregard of substantial risk: ignored policy, knowingly skipped required safety step, continued despite concern | Strong peer review action; possible privilege restriction or summary suspension depending on risk |
| Competence or training gap | Clinician lacks procedural skill, does not understand device/process, repeated technical errors | Focused education, simulation, supervised procedures, privilege limitation until competence demonstrated |
| System/design failure predominates | Kit design, staffing, interruptions, lack of standardized process, unavailable equipment, flawed policy | System corrective action; individual review only if behavior or competence concern remains |
The most important move is to separate outcome severity from behavioral culpability. A terrible outcome does not automatically mean reckless conduct. Conversely, a near miss can reveal reckless or incompetent practice.
What could be done differently for the review of procedural errors?
1. Start with an event review before judging the individual
For procedural never events, the first question should not be “Who is at fault?” It should be:
“How did the system allow this failure mode to reach the patient?”
Root cause analysis is intended to identify underlying conditions that increase the likelihood of error while avoiding an overly narrow focus on individual mistakes. The Joint Commission’s sentinel-event policy similarly frames serious safety events around protecting the patient, improving systems, and preventing recurrence.
For the example of the retained guidewire, the review should reconstruct the entire process. In essence we should be considering whether the individual took the usual and necessary steps to safely perform the procedure and what has been the performance of the provider over time. Consider the following:
Was there a central line checklist?
Was an assistant present?
Was the wire verbally confirmed removed?
Was the wire intact?
Was the operator interrupted?
Was the kit designed in a way that made loss possible?
Was a post-procedure chest X-ray reviewed?
Was the event discovered promptly?
Was disclosure made?
Was the clinician credentialed and recently competent for the procedure?
Was this clinician known to take shortcuts?
Were prior near misses reported?
This type of process review should occur even when the clinician obviously made the final manual error.
2. Use just culture, not “no blame” and not “automatic blame”
A just culture is not a no-accountability culture. It asks what type of behavior occurred. Human error is usually consoled and managed through system redesign. At-risk behavior is coached and corrected. Reckless behavior is subject to disciplinary action. AHRQ, ISMP/ECRI, and the Veterans Health Administration, all emphasize these distinctions.
So….the peer review question should be revised from:
“Did the provider meet standard of care?”
to:
“Was the provider’s care, decision-making, technical performance, and behavioral choice consistent with what a reasonably careful clinician would do under the circumstances, and were there system contributors that must be corrected?”
That phrasing preserves accountability but avoids scapegoating.
3. So, events such as retained guidewire events can be treated as “sentinel safety failures” BUT with a competency review overlay.
Guidewire retention during central venous catheter placement is widely described as a “never event.” AHRQ’s PSNet summary notes that retained foreign objects can cause serious clinical consequences and that most retained guidewires in one database analysis were identified after the procedure.
That means the response should be structured differently than an ordinary peer review:
Immediate patient management and disclosure.
Event report and safety review.
Preservation/review of equipment and imaging.
Procedure-process mapping.
Review of credentialing, training, supervision, and recent procedure volume.
Assessment for recurrence or pattern.
Corrective action for both the clinician and the system.
The individual clinician should not be excused simply because the system was imperfect. But the organization should not pretend that “be more careful next time” is an adequate corrective action.
4. Require different corrective actions than diagnostic-error cases
For diagnostic errors, corrective actions often include diagnostic reasoning education, cognitive forcing strategies, follow-up systems, second-read processes, escalation triggers, closed-loop test-result management, and feedback to the clinician. Diagnostic error literature commonly emphasizes cognitive bias, patient factors, system factors, and follow-up failures.
For procedural errors, corrective actions should be more concrete and engineered:
Use a standardized procedural checklist.
Require visual/verbal confirmation that the wire is removed.
Require the wire to remain under operator control.
Require an assistant/nurse to document wire removal.
Use post-procedure imaging review protocols.
Use simulation refreshers after serious events.
Use proctoring or focused FPPE if competence is questioned.
Consider kit redesign, forcing functions, or device-level safeguards.
There is literature specifically suggesting engineered solutions for guidewire retention. One paper on preventing retained central venous catheter guidewires argues that current prevention often depends on the operator remembering to remove the wire and describes a locked procedure pack designed using human-factors principles to force guidewire removal.
That is the right mindset: peer review should not merely ask whether the physician failed; it should ask why the procedure remains dependent on memory for a catastrophic, preventable failure.