Abstract
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.
MeSH terms
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Causality
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Health Services Needs and Demand
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Humans
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Medical Errors / methods
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Medical Errors / nursing
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Medical Errors / prevention & control
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Nursing Care / standards*
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Nursing Evaluation Research / organization & administration
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Organizational Culture
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Outcome Assessment, Health Care
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Peer Review, Health Care / methods*
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Pennsylvania
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Professional Staff Committees / organization & administration*
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Quality Assurance, Health Care / organization & administration*
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Risk Assessment
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Risk Management / organization & administration*
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Total Quality Management / methods