Elevating the Culture of Safety through Identifying Deviations In Practice through an Ambulatory Care Nurse Peer Review Committee

The American Nurses Association (ANA) introduced the concept of nurse peer review (NPR) in 1988. It was defined as a process by which registered nurses (RNs) systematically assess, monitor, and make judgments about the quality of nursing care provided by peers. As an ANCC Magnet®-recognized hospital, nurse-driven practice and evidence-based review opportunities are valued. Implementing NPR is one way to evaluate nursing care through formalized, systematic peer review nursing practices. A literature search was completed, yielding limited results in establishing an NPR committee within the ambulatory care space. However, literature exists describing development of an NPR committee within healthcare in general, which provided a foundation for the hospital’s effort to implement NPR. The purpose of this abstract is to describe application of the nurse peer review process to identify and solve for system failures in the ambulatory care setting.
In late 2021, ambulatory care services within a large academic health center in the Midwest United States developed an NPR committee and in 2022 the committee began their first peer review process. The NPR committee included the administrative director of multi-specialty services, the clinical educator for ambulatory care services, the ambulatory care clinical program manager for quality and safety, and eight direct care RNs. The NPR committee retrospectively reviewed all patient falls from 2020 and 2021 for their first event review. This exercise supported the council to formalize the NPR process, including gathering data from the medical record, facilitation of peer discussion, identification of deviations in generally accepted practice standards (GAPS), and generation of actionable items based on identified deviations.
In the first quarter of 2022, 45 incident reports were filed, of which 19 met criteria for NPR. The included reports were broken down as lab/diagnostic events (7), patient relation events (2), care delivery events (3), falls (2), surgery/procedure event (1), good catch/near miss (1), and safety event (1). The framework used to guide committee discussion was the Taxonomy of Failure Modes, which facilitated the team to identify system and individual failures and identification of associated follow-up actions. For example, review of fall events identified that the ambulatory care fall assessment was not a mandatory field in the electronic medical record as a part of the rooming process. Additionally, the review found the current fall risk assessment was not evidence-based, prompting a literature search that identified more comprehensive assessments, with evidence of validity and decreased harm events after implementation in the ambulatory care setting.
Overall, the NPR committee provided a collaborative and safe space to identify specific gaps that the team could act on immediately. NPR team members expressed satisfaction with the process and continued to be highly engaged through sustainment of the committee. When delivered in a psychologically safe environment, NPR can foster transparency and an in-depth approach to event review. Leaders in ambulatory care settings should consider integrating NPR to understand system and individual failures to more effectively align with strategic action plans that address and prevent further patient harm.