NPRC – Safety & Accountability

Reflecting on the Calendar Year 2012
By Adina Andreu, MS, CNM, RN, NEA-BCJC1

“Nursing peer review includes the evaluation of an individual nurse’s professional performance, the quality of patient care rendered by the nurse, and determinations regarding a particular incident that warrants review including the identification of opportunities to improve individual practice. “

“Peer review differs from other quality improvement processes in that it evaluates the strengths and weaknesses of an individual nurse’s performance. The individual’s evaluation is based on generally recognized standards of care.”

“Through this process, nurses receive feedback for personal improvement or confirmation of personal achievement related to the effectiveness of their professional, technical, and interpersonal skills in providing patient care.”

The quote above is taken from Policy PD-7 Nursing Peer Review. While the proceedings of the council are confidential, the council continued to conduct business in 2012 agreeing to hear four out of five cases that were referred. The case that was rejected was identified to be a unit wide issue that was immediately acted upon by unit leadership. The cases that were heard included situations related to medication administration, BMV compliance, and patient fall follow-up.

The Peer Review Council utilizes the Just Culture Framework to conduct a thorough investigation of the case by studying the patient chart and interviewing those involved. While the council is strictly advisory, the Just Culture algorithm is presented to the participants of the peer review process. By utilizing the Just Culture algorithm behaviors engaged in by participants are identified; Human Error, At-risk Behavior, and Reckless Behavior. Additionally any system problems associated with the event are also acknowledged.


Following the interview process, a written report is sent to the nurse(s) identifying how the nurse(s)’ behavior related to nursing standards, the CVMC Nursing Professional Practice Model, The Code of Ethics for Nurses and CVMC polices if appropriate.

At an end-of-the-year review by the members of Peer Review Council, the predominant feedback from members was how much participating in this process has improved their own nursing care. Observing how easy it is for even the most dedicated and diligent nurses to “drift” from what they have been taught has made council members become hyper alert to their own behavioral choices.


There are several ways in which a incdent or case reaches the Nursing Peer Review Council. Peer Review cases can be referred according to the algorithm below.