Peer case review sharpens event analysis.

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.

First do no harm: integrating patient safety and quality improvement.

BACKGROUND: Lehigh Valley Hospital's (LVH's; Allentown, Penn) interdisciplinary quality improvement program Primum Non Nocere (PNN), or First Do No Harm, is composed of 12 quality improvement (QI) projects that are a combination of ongoing operations improvement projects and new projects in patient safety. The projects stress delivery of cost-effective medical care while reducing preventable adverse events through improved communication, process redesign, and evidence-based protocol use. EXAMPLE: WRONG-SITE SURGERY: In response to an initial alert warning in 1998, LVH developed a policy of marking "yes" on the surgical site and "no" on the other side. However, several near misses occurred, and a root cause analysis indicated that the policy was not always followed for some very specific reasons. For example, the operative record included no prompt to address laterality, and the procedures in which laterality should be addressed were never specified. Interventions to address these issues were quickly developed that were in keeping with the recommendations outlined in a second alert warning on the issue in December 2001. A year after these stepwise changes, compliance with the policy is almost 100%, and there have been no further near misses. DISCUSSION: Specific project barriers included the initial challenge of changing the mindset in the institution from gradual change on a grand scale to smaller, more rapid changes, analyses, and actions. Another issue identified early in the initiative was the tendency of project groups to outline elaborate process improvements without determining how to measure and monitor success. A project sustainability is inherently linked to its initial strengths and the successful solutions to barriers that are encountered.