Nurse Peer ReviewBy Lindsey Uher BSN, RN & Jade Gearhart BSN, RN

Objectives• History

• Purpose of Nurse Peer Review (NPR)

• Committee Membership

• Case Referral

• NPR Responsibility

• Process

• Examples

• Trends & Themes

• Case Breakdown

HistoricallyPreviously utilized Incident Reporting

• Reviewed by staff nurse, manager, & patient safety coordinator

• Reports were intimidating

• Possessed a negative connotation

• Seen as "Tattle Tailing"

Switch to Shout Out for Safety (SOS)

• Thank you, Zero Harm safety strategies

• Reporting has increased by 40% since starting Zero Harm

• An SOS can now be filled out directly from EPIC making errors easier for staff to report

Purpose of Peer ReviewingNPR is designated for staff nurses to tell their error or near

miss stories to a peer driven committee to discuss the events

leading up to the mistake as well as preventative measures

through a means of storytelling.

The purpose of this committee is to improve nursing practice and make system enhancements through a culture of nurses helping other nurses.

Key Functions1. Ensure that the process for peer review is clearly defined, fair, timely, useful,

and effective.

2. Maintain confidentiality of all privileged information discussed during reviews.

3. Monitor and report trends by analyzing aggregate data derived from reviews.

4. Identify system and process issues and make recommendations aimed at mitigating risk.

5. Identify opportunities for improving the quality of nursing care.

6. Inform nursing staff of the presence and purpose of the Nursing Peer Review Committee.

7. Monitor and report quarterly and annual event trends.

8. Use established criteria to determine when a case brought to nurse peer review triggers a Root Cause Analysis.

MembersAdvisor

• Medication Safety Nurse Specialist

Staff Nurse Representation

• Intensive Care (2)

• Progressive Care

• Medical Surgical (2)

• Pediatrics

• Procedural Areas

• Ambulatory

• Emergency Department

• Specialty Care Areas (Chemotherapy Administration)

• Wound Care

• Nursing Staff Resource (2)

Case Referral

Event Reported Discussed at CERTCommunication

to management/

scheduling

Invitation to staff nurses;

managers cc’d as FYI

NPR Occurs

Core Event Review TeamReferrals for NPR are reviewed by the Core Event Review Team

• Physician Reviewers

• Clinical Quality Leads

• Medication Safety Pharmacist

• Medication Safety Nurse Specialist

• Chief Patient Safety & Compliance Officer

• Manager of Clinical Quality & Patient Safety

• Intensive Care Nurse Practitioner

• Risk Management Coordinator

• Chief Nursing Officer/VP Operations Ad Hoc

• Acute Care Services Director

Case Referral

Event Reported

Discussed at CERT

Communication

to management/

scheduling

Invitation to staff nurses;

managers cc’d as FYI

NPR Occurs

Committee ResponsibilityDeep Dive into EMR

• Nurse documentation

• Active orders

• Provider notes

• MAR

• Lab results

• Pump programing

Confidential Notification

• Original SOS

• Patient MRN

• Event Date

NPR ReviewMeeting with Involved Nurse(s)

• Introductions for all peers in the room

• Story telling beyond chart review

• Questions asked & answered

• Close the review process

• Share the story with colleagues

Advisory BoardMonthly meetings with the Chair & NPR Advisor

• Review of case findings

• Recommendations made

• Questions Answers

Members of the Advisory Board

• Chief Nursing Officer/VP Operations

• Executive Director of Practice & Informatics

• Risk Management Coordinator

• Medication Safety Pharmacist

• Patient Safety Coordinator

• Nurse Mangers & Directors rotation by case

Just Culture• Possible system induced error

• Deficiencies in related training, experience, or related training

• Broken and or non-existent process

• Possible unintended human error

• Lack of intent

• Possible reckless or negligent behavior

• Substantial, nonjustified, & conscious disregard

Recommendations Errors reported help create the real and impactful changes for the entire organization.

Common Recommendations

• Unit education

• Policy review

• EPIC building or changes

• WINK published for distribution

WINKWhat I Need to Know

• Error or near miss story within the hospital

• All specific information about event is de-identified

• Used to spread the word of error prevention

• Distributed weekly amongst all units

The Patient Safety WINK:What I Need to Know

Situation: Failure of staff to validate and verify

Background: Several incidents have occurred where staff nurses or leads have not known how to handle a situation and instead of escalating to another resource, they “guess” or neglect to seek other resources.

Assessment: In 2017, 10% of cases that were reviewed via Nurse Peer Review had a theme of Lack of Escalation.

Recommendation: Always have a questioning attitude! When in doubt, staff nurses should seek their leads as a resource. If the lead doesn’t know what to do continue to validate and verify by escalating to other resources such as:

Policies

SWOOP

Nurse Resource Coordinator

Providers/Attendings

03/30/18

Real Case Review

Personal Account of Events:

Map 74, parameters for medication map of 80 hydralazine given

Question Time

Peer Review Findings• RN felt very overwhelmed & distracted this shift

• Patient assignment: 3 LVADs, 1 with a GI bleed

• During med pass, RN thought she knew this long term stay patient and his meds very well

• Most patients have parameters for MAP hold of 60-65

• This patient’s parameters for MAP were 70-90

• Gave the hydralazine when the MAP was 74

• Hold parameters were <80

Case Recommendations• Review parameters and med hold orders during bedside report

– preferably while using ISHAPE

• Change administration instructions on the MAR

• Move location to be near vital signs

• Patient/Preceptor assignments

• Is 3 LVADs and a busy 4th patient a normal assignment?

• Do new orientees have their LVAD class prior to taking care of LVAD patients? Would this had made her more comfortable?

Personal Account of Events:

Patient is a fairly sick individual with severe liver failure. Our team has been treating his foot wounds that are slow to heal. He has undergone alloderm placement on these three regions of wounds and the alloderm failed. He underwent a second skin graft; split thickness skin graft from his donor site. He is post operative day six on day of incident. We have been managing his wounds with a wound vac.

The night of the incident, The doctor and I replaced a new wound vac at approximately 8:00 - 9:00 pm.

At 11:12 am the next morning, I receive a perfect serve saying " the night nurse had to remove the wound vac last night for leaking and tried to find wound care orders. Does this need to replaced, foot is currently wrapped "

Upon further investigation, plastic surgery was paged at 6:40 am for this issue. Considering the patients difficulty healing his wounds, this was a very dangerous thing to do. One of the grafts might have been compromised due to this.

Question Time

Review Findings• 5/23 Night shift RN

• Wound vac on donor site began beeping around 0600• RN attempted to reseal, but vac was dislodged• RN conferred with Lead to remove & start wet to dry dressing changes per

policy (policy states to never remove wound vac from donor site)• RN Perfect Serves resident – no response

• 5/23 Night shift Lead• RN looks at notes from team to see what to do• Primary team called back & said another team manages wound, so they

would not write orders for dressing changes• There was no number to call for this other team

• 5/24 Day shift RN• "Busiest and worst day as a nurse, it was a nightmare"• Patient was confused & uncooperative• Fellow came to bedside to yell at RN for taking off wound vac, made scene in

patient's room, & spoke with Lead & RN's manager

Case Recommendations• Education

• Donor site care

• Wound care policy

• Wound vac management

• Change order set for Donor Sites

• Clearly identify that would vac should be left in place

• Assign a pager number to all teams

• Make contact information available to all nursing staff

Outcomes• Independent Double Check Education/Competencies

• Updated Lexicomp

• Facilitated unit education on several different topics

• Collaborated with colleges when students involved

• Convened work group related to medication dilution

• Facilitated changes in One Chart

• NPR Advisory able to support management with employees that demonstrated worrisome behaviors

2018 Trends & Themes

2018 Case Breakdown 5 rights

Wrong route x 3

Order parameters not met

Furosemide 300 mg bolus

Pump programming error

Wrong med administration x 3

Lack of escalation

Wound vac x 2

G tube rupture

Nitro titration

Deviated from policy

Retained object

Lab labeling

Dobhoff insertion

Fall

CIWA protocol

Distraction

Crossing of insulin/NS lines

Wrong med administration x 2

n/a x 3

Ineffective handoff

Missed anticoagulation drip

NG tube misplacement

Documentation

Medication administration

Lack of Supervision

Platelet administration without consent

Ineffective Communication

Communication of BG results

Lack of education

Titration of insulin drip

Lack of assessment

Infiltration event

Ineffective Dual check

Heparin/NS lines crossed

Questions?