Physician peer review: just culture and practical implementation in an emergency department

Although regulatory agencies require hospitals to engage in peer review to maintain accreditation, quality assurance review processes are not standardized, and well-structured peer review of clinical cases involving medical errors and adverse events governed by Just Culture principles is not widespread. We implemented such an emergency department (ED) physician peer review process and performed an analysis of cases that underwent review. We formed an ED physician peer review committee at our institution guided by Just Culture principles, including promotion of a culture of safety to encourage open reporting of errors and near misses, and top-down leadership commitment to focus on identifying systemic factors contributing to human error, thereby creating opportunities for shared learning, rather than punishment and retribution. Using an existing database, we conducted a retrospective analysis of 282 clinical cases reviewed by the committee between July 2019 and June 2022, describing the sources of case referrals, case management attribution determinations, identified opportunities for improvement, post-review actions taken, and systems-related contributing factors. 282 clinical cases were reviewed between July 2019 and June 2022. The most common sources of case referral were ED faculty (n = 108, 38.3%), external hospital departments (n = 51, 18.1%), event reporting system (n = 39, 13.8%), mortality chart reviews (n = 15, 5.3%), and ED nursing (n = 8, 2.8%). The committee determined that “most practitioners would have managed care similarly” in 142 cases (50.4%), “similarly, with opportunity to improve” in 99 cases (35.1%), and “differently” in 39 cases (13.8%). Attribution determinations and their distribution were similar between calendar years. This study demonstrates that physicians can engage in a structured peer review process guided by Just Culture principles that promotes physician learning and faculty development, while also identifying competency and systems-related contributions to clinical care that enhance patient safety.