An elderly patient presented with severe shortness of breath. Based on a specialist’s interpretation of a diagnostic study, an emergency procedure was scheduled for a potentially life-threatening condition. However, the patient refused the intervention. The patient was observed, managed conservatively, and slowly improved. When the diagnostic study was later repeated, no serious finding was noted. The original study was re-reviewed, and it became clear that no life threatening condition was actually present and that the emergent intervention never should have been recommended. The only reason the emergency, high risk intervention was avoided was because the patient refused to proceed. The facility requested outside peer review for what was considered internally as a “near miss.”
An otherwise healthy 40-year-old is nearing the end of a three-day hospitalization for an acute asthma flare. Discharge is planned for the following morning. Nursing notes a sudden change in mental status and the patient reports a severe headache. Rapid response team emergently evaluates the patient, and a CT scan shows a large spontaneous subarachnoid hemorrhage. The patient is intubated, transferred to the ICU, and seen within two hours by neurosurgery. Despite aggressive management and urgent operative intervention, the patient does not survive. Nursing and physician providers are devastated by the unexpected turn of events, and they request outside peer review to assure no potentially helpful elements of care were missed.
As these cases illustrate, assessment of competency of care must, in most circumstances, be separated from clinical outcomes. Patients sometimes escape adverse outcomes despite care that falls below accepted standards. Conversely, meticulously expert care can sometimes fail to save a patient from a lethal clinical course
Limiting case review to those involving adverse or unexpectedly negative outcomes misses opportunities for identifying areas for improvement in processes, communication, training and education, resource utilization, and clinical decision making. The airline industry has enhanced its safety record in part by encouraging open and transparent reporting by any employee of near-miss circumstances that could have, but did not, affect passenger safety. Medical facilities are finding similar success by focusing review efforts on reports from any member of the care team of near misses, core measure outliers, or other variations from usual practices, without any evidence of patient harm or adverse outcomes. Providers devastated by an unexpected death or disabling event can be reassured by a detailed review of care that determines all reasonable assessments and interventions were performed competently.
Hospitals are increasingly enlisting the help of external peer review to get the most objective evaluations they can, even when outcomes appear acceptable. MDReview’s expert reviewers are often intentionally blinded to clinical outcomes in order to avoid introducing any bias during evaluation. Without knowing the patient’s outcome, our peer reviewers can focus on evaluating the clinical care as documented, knowing that their assessment of the reasonableness of care will not be affected by the clinical “punch line.”
One recent review focused on an ED patient with complex psychiatric conditions and active psychosis complicated by substance abuse. The reviewer concluded that his discharge from the ED was premature, lacked documentation of return to baseline mental status, and failed to address availability of outpatient resources. The reviewer had been blinded to the fact that, soon after discharge, a critical behavioral adverse event occurred. This blinding helped the conclusions of the review hold up to scrutiny.