Keywords

case review, peer case review, peer review, quality of care, root cause analysis

Authors

1. Hitchings, Kim S. MSN, RN, NEA-BC
2. Davies-Hathen, Nancy MSN, MEd, RN, NEA-BC
3. Capuano, Terry Ann MSN, MBA, RN, NE-BC
4. Morgan, Georgiann RN
5. Bendekovits, Rita MSN, RN, ONC, CRRN

Abstract

This manuscript describes a scholarly approach to peer case review that identifies and analyzes quality-of-care issues in response to a question about nursing care of a specific patient. The comprehensive method provides a structured format that critically examines untoward patient events, generates an awareness of gaps in care from a systems perspective, ensures action planning focused on legitimate root causes, stimulates performance improvement initiatives, and provides a forum to share learning throughout the organization.