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Has Your Hospital or Department Had an Unexpected, Tragic Outcome?


Do you have a devastated care team that is struggling to understand how and why this unexpected tragic outcome occurred? External Peer Review can help you to determine if opportunities for improved care exist – or whether there was a bad outcome despite excellent care.


When BR was admitted to the hospital with fever and respiratory symptoms, there was nothing to indicate the young, otherwise healthy patient would not return home. Diagnosed with an acute respiratory illness, she was started on timely and appropriate treatment. She stabilized and showed continuous improvement over two days, leading her team to prepare her for discharge on day three. And then, unexplained nausea and sudden changes in her mental status brought that plan to an abrupt halt. The multidisciplinary team quickly assessed her symptoms of headache, nausea, facial droop, and abnormal behavior, and an urgent CT scan revealed a large, acute intracerebral hemorrhage.


MDReview’s external peer reviewer, an experienced hospitalist at a leading institution elsewhere in the country, scoured the patient’s extensive medical records and imaging. She determined that the team’s evaluation (including angiogram, MRI, CT, lab tests, and more) was both thorough and timely. Despite receiving entirely appropriate care, the patient had suffered a spontaneous hemorrhage that occurred with little warning, and only coincidentally during her hospitalization for an unrelated problem.

“Once she developed acute neurologic deficits, the team moved very quickly,” noted the reviewer. Emergent imaging of the brain identified the bleeding, and the patient was seen by critical care, neurology, and neurosurgery within a few hours. Aggressive and appropriate critical care followed, but none of the surgical or medical interventions could reverse her course, and she expired on day 13.

BR’s death shook the team’s confidence. Devastated by this tragic course of events, her doctors and nurses urgently wanted — needed — to know: Did they miss something? Did they fail to recognize her neurologic symptoms in time? Was there an error in medication? How could this have happened, and what could they do to avert this kind of event in the future?

MDReview’s expert reviewer was clear that the outcome occurred despite consistently good care by BR’s team. “The initial admission was performed appropriately. There was no indication of any neurologic issue at the time of admission. When the patient was noted by nursing staff to have an acute change, her medical team acted quickly with the appropriate diagnostic tests and use of consultants. Interventions were performed in a timely manner when indicated. There did not seem to be any point in her care when warning signs were missed or interventions were delayed beyond standard of care.”

In short, the team did everything correctly and they did it well.


How did this external review serve the treating hospital? Despite the internal review that had been completed, the medical staff shared a strong feeling that they needed a definitive outside opinion. In this case, the unbiased report provided invaluable information that could not have been obtained any other way. It confirmed that the team had provided consistently high quality care and reassured the providers, many of whom had felt responsible for the unexpected outcome.