Peer Review Insights

Risk & Patient Safety Leaders share insights on the shortcomings and benefits of peer review.

  • 00:10:11 - 05:10:11

    Dr. Husam Bader 00:06

    Yeah, it's a, I think it's something I found online is while I was doing my, my mind my manuscript my articles, it seems that 65% of the physicians felt that the clinical peer review process was not helpful. 30% did not know it existed in their hospital. And that's why I called it Assam as it really not. It's not out there, it's not doing what it's supposed to be. There, there are so many types of biases, or let's call them cognitive biases. And the two that I was stressing upon in my article that I think are relevant to clinical peer review, are the outcome bias and the hindsight bias. And those two I think, are very common when it comes to a process of clinical peer review. Or even things that are related to this, like mortality and morbidity or root cause analysis. We have to be cognizant of those. And it's a very tricky topic. Because just being aware of it or talking about it, it's not enough to eliminate it, we have to be really doing more is knowing the outcome, knowing now that you know the outcome, it makes you exaggerate the likelihood of having no advance beforehand.


    Jerrod Bailey 01:32

    Okay, so something bad happened. Now I'm being reviewed, but they know the outcome. So knowing that as they're looking through the medical record, and what happened there, what does that what does that look like? So what's How's, how's the hindsight bias playing out


    Dr. Husam Bader 01:47

    there, right? Let's say, a patient comes in, and you're doing a lot of tests or a lot of imaging, and in a day or two about about the outcome happens. Then I'm reviewing this, and I look at the outcome, and I'm like, Wow, this patient passed away. Then I look back at the events. And now because I know that come I know the outcome, I would probably exaggerate or I would have this delusion that I would have known that this happened. And I wouldn't be looking at the labs. I'm like, Oh, you see this was a little bit high. Had I seen this, I would have known that the outcome would be bad. And that's really easy, because I'm looking at things in retrospect. Yeah. But this is not how clinical practice happens. We don't look at things in retrospect, we looked at things in fortnight. The


    Jerrod Bailey 02:47

    problem that I think we're all sort of aware of is that peer review is done today. It's often involving, you know, internal resources, reviewing each other. And while that can be wonderful and wonderful practice and is, if it's the only way that peer review is happening, I think we're we're we're seeing the sort of, you know, the chinks in the armor in some of that, right? We're seeing I mean, if you've seen it, too, you know, you've got, you've got partners reviewing each other, you've got competitors reviewing each other, and the data that comes out of that process isn't necessarily data that's helping anybody.


    Dr. Ara Feinstein 03:26

    Yeah, absolutely. I mean, I think, you know, it's the, the, you know, the, the, the right to trial by a jury of your peers, but, you know, in, in the legal system, if you know, those people, they are excused from the jury, right. Whereas, often in in our peer review process, we are reviewing people that not only we know them, there are partners, and as we discuss these things, they're in the room with us. And it would be I think, in an ideal world, it wouldn't matter and we would look at these cases, absent, who were the the caregivers in that situation, but it's really hard to do, whether whether it's conscious or subconscious, when you know that the person you're reviewing is, is your partner, and you know everything about that person, and, you know, you also know what kind of stressors they're under, and, you know, the, some of the mitigating factors. And frankly, you also know that they're going to be reviewing you. And the old saying, people, glass houses shouldn't throw stones comes up a lot in peer review, right? It's, it's, it's, you know, that you, you know, you're going to have a complication, and you're gonna be in that scene at some point. And so, all of these things, colors that process and make it so that it's not exactly what But it's intended to be, which is this very unbiased review with the idea of getting to the truth. And in getting to the truth that you may be find systematic or decision making elements that could have been done differently so that you can not have that happen again.


    Dr. Stephanie Sanderson 05:28

    I know that as a nurse, I've made multiple, multiple mistakes. I've I've made medication errors, I've made treatment errors, I've, I've done the wrong thing to the wrong page. I've done that. I know that I have. And I bet that I'm going to make more. And I know that my nurses are going to make mistakes. And when they do make a mistake, what I try to do is is to coach them, everybody needs a coach, it doesn't matter how long you've been doing something, how can we do this better? How did this happen? Tell me how this happened. Because maybe I can intervene. And this is a system problem. I tried to look at it that way. I tried to these are not bad people. This might be a bad process. So there's a nurse outside the door mouthing to give 2000 units of heparin. The nurses in the room thought he said 10,000 Yeah, oh, my goodness Heparin, they didn't double check that they didn't verify that they didn't wait for an order that said that, because they trusted the nurse giving them right directive. And two and 10, behind a glass door looks the same. If you're reading Yes, it does. And if you're wearing a PAPR, and you're Yeah, hot, and the situation is very stressful. And so when I found out what was happening, I really, really sat down with myself to rehearse how I was going to address this because I was afraid that these nurses would deteriorate pretty rapidly if they knew that they had made this big error. And that, and that it could have caused this horrible harm in this patient who was already so incredibly sick. And so we sat down, and we had a very open dialogue about it. And I did not see it as like negligence, they, they could have done a few things differently. But in that moment, I gave them that grace, which they deserved, because they were in a very, very difficult situation. Now we talked about the all the things they could have done to have avoided that. But neither one of those nurses quit. Neither one of those nurses called in sick for the next month, because they felt so bad about what had happened. And I believe that that was because we really worked hard to preserve their integrity over all of this.


    Kara Knowles 08:20

    I just feel like it's been better since we've been doing the external reviews. And and the information is, is just really, really good. And the the reviews that we've got. And I think the way that they have stated things that could be done differently, was tactful. And I just think a lot of how they put it did not make them feel like they were being punished or for I mean, I think it was just truly from a standpoint of you might want to think about this, or I might have done this and consider that. And so I think that helps a lot with the defensiveness and, you know, and I think the peer review committees that we the meetings we had, they, they were really good, they all talk together, they, you know, basically, and even the position that maybe the concern was with when they actually came to the table for the committee. They had done some good thinking on what they should have done differently. And so, I mean, I think they, I don't know, I felt like there was just, uh, it just kind of grew to be a much better attitude about it. I think they understood the reasoning we're doing it and that it's quality and the patient, what's best in the long run and that was our goal and I think they grew to understand that again,

Dr. Husam Bader connects cognitive biases to peer review shortcomings while giving useful statistics on how hospital staff feel about these systems. Next, Dr. Ara Feinstein explains the nuances of peer review when internal politics, close colleagues, and competition may result in a biased review.  Dr. Stephanie Sanderson tells her story of a medical "close-call" and how a review climate without fear can improve care. Lastly, Risk Leader Terri Schimmer shares how external experts revolutionized Cherokee Regional Medical Center's peer review process.


Multiple Contributors

Experts Across Healthcare


Husam Bader, MD - Internal Medicine Physician

Ara Feinstein, MD - Trauma Surgeon at Banner Health

Stephanie Sanderson, CNS - Nurse Leader at Sharp Memorial Hospital

Terri Schimmer, RN - Former Risk Leader at Cherokee Regional Medical Center

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