Case Study: Sentinel Concern

Situation:

• A medium sized tertiary care facility experiences a patient demise less than 24 hours after nonemergent neurosurgical intervention
• The physician is aloof, a poor communicator and tenured
• Review by peers is nonconclusive
• The family is asking questions
• 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:

• Physician reviewer selected, credentialing and appointment to the Medical Staff
• Offsite record review against selected criteria
• Report development including data analysis trending and determination of standard of care questions
• Approaches for improvements given
• Conference offered, not required as report answered Medical Staff Executive Committee's concerns

Peer Review Study Conclusions:

• 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:

• Medical Executive Committee is evaluating options at this time