Using Peer Review to Prevent Repeat Adverse Events

Adverse events are among the most challenging issues healthcare organizations face. Beyond the immediate impact on patients and families, they raise concerns about system reliability, provider performance, regulatory compliance, and organizational risk. While no healthcare setting can eliminate adverse events entirely, repeat adverse events are often preventable. A structured, objective peer review process is one of the most effective tools organizations have to break this cycle.

Understanding Repeat Adverse Events

Repeat adverse events rarely stem from a single isolated mistake. More often, they reflect underlying patterns such as workflow gaps, communication failures, unclear clinical guidelines, documentation issues, or system-level constraints. When these root causes are not fully identified and addressed, similar events can recur, sometimes involving different providers but the same vulnerabilities.

Peer review provides a formal mechanism to identify these patterns early and intervene before they become systemic.

Moving Beyond Blame to Root Cause Analysis

A common misconception is that peer review exists to assign fault. In reality, effective peer review focuses on distinguishing between:

• System-related issues such as staffing, access to diagnostics, handoff failures, or EHR limitations

• Process gaps including unclear protocols or inconsistent application of standards

• Individual performance concerns that may require education, monitoring, or focused professional practice evaluation (FPPE)

By analyzing cases through this lens, peer review helps organizations avoid superficial conclusions and instead address the true drivers of adverse events.

Identifying Trends Through Structured Review

When peer review is conducted consistently, it allows organizations to identify trends that may not be apparent from a single case. For example:

• Repeated delays in diagnosis across different providers

• Similar documentation deficiencies in high-risk encounters

• Patterns of deviation from evidence-based guidelines

Tracking and aggregating peer review findings enables leadership and quality committees to see where corrective action will have the greatest impact.

Translating Findings Into Preventive Action

Peer review is only effective when findings lead to action. Preventing repeat adverse events requires closing the loop by:

• Updating clinical protocols or policies

• Improving communication pathways and escalation processes

• Providing targeted education or mentoring

• Implementing OPPE or FPPE when appropriate

• Addressing system constraints that limit safe care delivery

Importantly, these interventions should be proportional, fair, and clearly linked to peer review findings to maintain provider trust in the process.

The Value of External and Independent Review

In high-risk or sensitive cases, external peer review can add an essential layer of objectivity. Independent reviewers are better positioned to:

• Reduce internal bias or conflicts of interest

• Provide specialty-specific expertise not available internally

• Strengthen the credibility and defensibility of findings

This is particularly valuable when adverse events have regulatory, legal, or reputational implications.

Fostering a Culture of Safety and Improvement

Organizations that use peer review effectively view it as a quality improvement tool, not a disciplinary mechanism. When providers understand that peer review is designed to improve systems, support professional growth, and enhance patient safety, engagement improves and resistance decreases. This cultural shift is critical to preventing repeat adverse events.

Conclusion

Preventing repeat adverse events requires more than reactive responses. It demands a proactive, structured approach to learning from past events and addressing their root causes. Peer review, when conducted consistently, objectively, and followed by meaningful action, is a powerful mechanism to improve care, reduce risk, and protect both patients and providers.

By transforming adverse events into opportunities for system-wide improvement, peer review helps healthcare organizations move from recurrence to resilience.