As a nurse with 5 years of experience, JT feels fairly confident in her practice as a clinical nurse in the intermediate care unit. One day she is assigned to care for a middle-aged patient admitted for acute kidney injury. JT learns in report that the patient's hospitalization has been complicated by a bowel obstruction related to scar tissue from previous abdominal surgeries. She notes that the patient's abdomen is distended and taut, but he has refused a nasogastric tube and insists on eating. His family accuses JT, other nurses, and several of the patient's physicians of “starving” him due to his “nothing by mouth” (NPO) status. They convince his physician to order a diet for him on the premise that his most recent radiologic studies showed improvement and he'd had no nausea or vomiting in the previous 24 hours.
Although JT is uncomfortable with the treatment plan, she complies under pressure from both the family and physician. She notes that the patient's distended abdomen appears to be impairing his breathing, as he cannot lie flat for any extended period without becoming short of breath.
Midway through JT's shift, the patient leaves the unit for a diagnostic study and is gone for an hour. About 20 minutes after returning to the unit, the patient was found unresponsive. Quickly confirming that he is apneic and pulseless, the staff initiates resuscitative efforts. Spontaneous circulation returns and the patient is transferred to the ICU.
JT thinks back to earlier in the day and wonders what went wrong. Could this patient's decline have been prevented? What could she have done differently?
FAILURE TO RESCUE is a concept that can be defined as loss of life among hospitalized patients resulting from inadequate recognition and treatment of life-threatening complications.1 Failure to rescue can also lead to a loss or decline in function or quality of life. Prolonged hospitalization and subsequent readmissions, extensive follow-up treatment, loss of the ability to work, and dependence upon others to help with basic needs or financial support can also follow these types of errors.
This scenario and many other similar cases happen daily in nursing, but there is often a lack of follow-up and/or follow-through that could prevent reoccurrences.2 Did JT's experience constitute a failure to rescue? What could have been done differently to prevent the cascade of events that led to the patient requiring a higher level of care?
Situations like these were the premise for the development of a Nursing Peer Review Committee at a 525-bed urban Level I trauma center. This article explores how the committee was implemented.
What is peer review?
The American Nurses Association (ANA) introduced the concept of nursing peer review in 1988, defining it as a process by which RNs systematically assess, monitor, and make judgments about the quality of nursing care provided by peers as measured by professional standards.3 The ANA went on to suggest that peer review should focus on maintaining and elevating the standards of nursing practice in the areas of safety and quality, role actualization, and practice advancement.
Our trauma center employs nearly 1,800 nurses to help care for over 26,000 patient admissions each year, and it receives acutely ill patients from 100 miles away and beyond. The hospital promotes an environment of safety that focuses on teaching and mentoring among both the nurses and the dozens of medical students, residents, and members of other disciplines who rotate through annually.
Although efforts were made to maintain transparency in communicating errors and opportunities for improvement before the committee was developed, staff often learned about only the major issues that caused significant harm. The hospital's Advanced Practice Nursing Council (APNC), which is made up of clinical nurse specialists (CNSs) and nurses who are in school or planning to become a CNS, recognized the need for an avenue through which clinical nurses could discuss nursing issues and identify opportunities for improvement. The council soon learned that one of the nursing directors was also tasked with implementing a peer review process, and the decision was made to collaborate on an initiative to develop a nursing peer review council with the director becoming the executive sponsor for this initiative.
Previously, care concerns had been evaluated by the Quality Improvement (QI) department, risk management, pharmacy, or other departments who would bring the issue to the manager and the CNS or nurse assigned to the unit involved. The clinical nurse at the bedside would typically meet with the manager and CNS/nurse to discuss the issue, and those nursing leaders would report the findings from their follow-up, as appropriate, back to the referring department. If the incident was considered significant and impacted patient care, a full root cause analysis would be initiated by the QI department at the direction of hospital administration. This analysis would be performed by a team comprised of both clinical and nonclinical staff (such as lab technicians, security, and chaplains). While this process is effective in learning what occurred, it does not include a standard, transparent method of communicating the findings in a way that could be useful to other nurses. A true analysis of the nursing care component was also not occurring.
Our first step was to gain buy-in and support from the directors of nursing and our nurse executive. A proposal outlining the need for and potential benefits of a Nursing Peer Review Committee was drafted by two CNSs who would lead the project. A mock outline of the process to be taken was also presented in a visual depiction.
With support from our executive sponsor, the proposal was presented to the nurse directors and nurse executive. With a few minor changes, the proposal was accepted in July 2015 and the true work of forming the team began. An action plan outlining high-level operational tasks was developed and included:
- conduct a literature search focusing on incident-related peer review
- develop the intended structure
- gain nursing leadership support
- recruit members and schedule meetings
- provide education.
We set a goal of having the first meeting occur in the third quarter of 2015 and set a date to initiate the committee in October.
Guidelines for membership were developed to ensure participants were experienced nurses who represented all levels of care and most care settings throughout the hospital. Though nurses could volunteer to become members, they had to be approved by their manager for membership. After members were chosen, each nurse received a personal note of thanks from the nurse executive for volunteering to be a part of this important group.
Besides identifying appropriate individuals for membership, the project leaders also developed logistical tools that included standardized forms for referrals, manager notifications when referrals were made, team summary, confidentiality, and guidance documents for the members who would be performing the reviews. A secured, shared directory was obtained to house all documents related to peer review and each member was given access following the initial meeting.
The agenda for the first two meetings was determined to be educational, with guest speakers from the QI and Risk Management departments presenting information on interviewing and medical record review techniques. The project leaders also presented methods for seeking out relevant policies and procedures and current evidence.
The peer review process incorporated the ANA Nursing Scope and Standards of Practice while using a practical approach to categorizing opportunities for improvement identified in the referrals. A brief overview of the standards was presented during those two formative meetings.
Referrals could be received from various sources such as QI, risk management, CNSs, and even ancillary departments such as radiology and pharmacy. An email account was created and advertised regularly in the hospital's daily newsletter to allow anyone to submit a referral for concern. Although submissions were not anonymous, the account was monitored by members of the APNC. Senders would receive acknowledgment of the email, but no further communication occurred unless clarification was needed. The first two referrals were presented during the third meeting.
Initially, we received multiple referrals from various sources. Two referrals submitted by our radiology department were determined to be unit-specific issues and were forwarded to the department leadership for follow-up. The first few referrals that went to full committee review in those initial months, though, were poignant in setting the tone for future meetings and reviews.
The first referral involving a patient who was inadvertently discharged without an order was initially thought to be straightforward. This referral was submitted by our vice president of medical affairs, who was concerned that this may not have been an isolated issue. Careful analysis and discussion determined that this was related to human error and other causative factors related to high capacity and fast turnover coupled with a relatively new nurse and a patient who had verbalized the expectation that she'd be discharged that day. These circumstances ultimately resulted in the perfect storm for an error to occur. It was recommended that unit leadership reinforce elements of the discharge process as well as ensure that all nurses, especially novice ones, know their local resources when questions arise. Additionally, a recommendation was made to our documentation team to consider having the system issue an automatic alert when nurses attempt to discharge patients when no order is present. This referral reinforced the need to remain unbiased and to not assume that a referral is “easy” or “straightforward” until a thorough analysis was been completed.
The scenario described at the beginning of this article was another referral that was reviewed by this team. This was an especially complex review in which family dynamics, frequent refusal of treatment by the patient, and multiple providers from various specialties played key roles in the resulting event. Further, with at least six specialties and a multitude of residents, nurse practitioners, and physician assistants participating in the patient's care, staff was often confused about which provider to call for which issue.
In this case, the patient's abdomen had become increasingly distended and his breathing compromised. The test he had left the unit for before the cardiac arrest required him to lie supine for an extended period; much of that time was spent unattended by staff. He was taken to surgery that same night and extensive bowel necrosis was found. He survived the surgery but died soon after.
This case was presented at our hospital's first Nursing Morbidity and Mortality presentation where escalation of concerns, clarification on appropriate provider notification, and critical thinking were highlighted in addition to tips for working with challenging families. This particular referral was also submitted for physician peer review, which was conducted by a separate group.
Having representation from medical-surgical, step-down, and critical care settings was extremely beneficial in this referral because each level had different priorities and skill sets. While the critical care nurses felt this poor outcome could have easily been prevented, staff from other levels vehemently disagreed. They had experienced the juggling act necessary to manage an acutely ill patient who is decompensating along with three to five other patients with limited assistance from unlicensed assistive personnel. The group was able to see this case from various points of view and come to a cohesive conclusion and list of key learning points to be communicated to staff.
Escalation of concerns was another theme that arose with this situation. There were times when nurses brought concerns about a patient's condition to the resident or attending physician but did not receive an adequate response, which occasionally led to delays in addressing those issues. Fear of angering the physicians or the family were discussed as potential contributors for not escalating when problems went unaddressed, but we also had to acknowledge that with the large number of novice nurses working in our facility, knowledge deficit was also a strong possibility. Despite the confusion that can occur when a nurse is trying to reach the appropriate provider, no formal education or tools are provided for new staff to help them navigate this issue. This review prompted nurses (both leaders and clinical staff) and physicians to team up to work through this dilemma. Additionally, more direction having a questioning attitude when something does not seem quite right was included in one of the onboarding classes that all newly hired nurses attend.
Trends and future directions
The foundation of the Nursing Peer Review Committee was and continues to be the facilitation of a just culture, one in which problems are openly and honestly reported to promote a quality learning environment.4 We recently celebrated our third year in existence and feel like we have held true to that goal. Though we originally set a 2-year membership cap, the group later revised that restriction in the charter to allow those active and engaged members to remain with the group as long as they wish and are able to participate in the monthly meetings. While many of the same members remain on the committee, we have also experienced substantial turnover as members transition to new positions or leave the committee at the end of their committed time.
The group was chosen to meet with Magnet® surveyors during the hospital's redesignation process. All in attendance agreed the committee has positively benefitted their nursing practice and has allowed them to better help their peers, both new graduates and experienced nurses, in their nursing practice.
The group has successfully completed over 30 reviews as of January 2020. The findings of each referral are presented to nursing leadership and nursing practice councils through a blinded summary of the event (patient and unit are not identified) and a summary of key “take-home” points. While many valuable lessons learned have been communicated, it is difficult to truly quantify the impact this committee has had on nursing practice. Our struggles around this mirror the findings of a systematic review performed by Routs and Roberts in 2008, which noted a considerable amount of literature about the formation of peer review committees but a lack of measurable outcomes.5
However, the committee identified definite trends that have brought about changes or additions to educational offerings and procedures. Below are a few significant findings and the subsequent changes:
- After I.V. adenosine was administered to an unmonitored patient, prompts were added in the medication vending machine to ensure that upon removal of this high-risk medication, the nurse has the patient on a monitor with an Advanced Cardiovascular Life Support-certified nurse present. Multiple referrals identified that appropriate supervision, or lack thereof, may have contributed to the incident. As a result, the APNC is developing a charge nurse development workshop to educate current and potential charge nurses on key elements of this important role.
- One referral involved a patient with a vacuum-assisted wound closure device who experienced significant bleeding from the wound site followed by a cardiac arrest. This case shed light on the knowledge deficit around the required assessment, monitoring, and documentation of patients with these devices.
- Another referral noted that while the nursing care provided was stellar and well-documented, an order set that was used for the patient was ambiguous and had the potential to lead to errors. Fortunately, the nurse caring for the patient was very experienced and managed the situation appropriately. As a result, the organization implemented order set changes and changes in the drug library of the I.V. pumps.
- One referral was received for a patient who experienced severe subcutaneous emphysema that ultimately required endotracheal intubation for airway protection, surgery, and an extended hospitalization. Investigation of the referral exposed the need to reiterate the escalation process when nurses feel their concerns about patient conditions are not being appropriately addressed. This also led to further investigation by the physician peer review team to ensure the many residents and specialties involved in the patient's care had also provided appropriate care and follow-up.
- Findings from two referrals have led to the initiation of nursing morbidity and mortality rounds, which allows more clinical nurses to listen to and actively discuss a review with others in attendance. Evaluations for these two events were extremely favorable, so quarterly morbidity and mortality rounds have been planned during which referrals from the peer review committee will be presented for open discussion.
Moving forward, the team plans to review all cardiac and respiratory arrests on inpatients that occur outside of the critical care setting to identify early warning signs and trends. Additionally, the committee would like to determine a more quantifiable measurement of the effectiveness of the team's efforts in reviewing our referrals. Another limitation of our current process is that it reviews issues reactively, rather than proactively. This approach, however, does help shed light on these issues so that staff can learn from them and processes can be evaluated to identify opportunities for improvement. Ultimately, the aim of this committee is to promote and facilitate quality patient outcomes across the organization.