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Case Studies >
 Case
Study: Sentinel Concern
Situation:
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A medium sized tertiary care facility experiences a patient demise less than 24
hours after nonemergent neurosurgical intervention
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The physician is aloof, a poor communicator and tenured
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Review by peers is nonconclusive
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The family is asking questions
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Time is of the essence
QMCG Team Role: Conduct an independent and timely review of the
physician's clinical performance using a five step process:
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Physician reviewer selected, credentialing and appointment to the Medical Staff
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Offsite record review against selected criteria
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Report development including data analysis trending and determination of
standard of care questions
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Approaches for improvements given
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Conference offered, not required as report answered Medical Staff Executive
Committee's concerns
Peer Review Study Conclusions:
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Multiple evidence of lack of documentation of critical events. Pre-operative
diagnosis and surgical justification were not found. Intraoperative events
correlated to post-operative demise.
Medical Staff/Hospital Accomplishment: Since receipt of the QMCG
report:
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Medical Executive Committee is evaluating options at this time
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