A new issue of JAMA: Surgery includes an article: “Erosion of Peer Review and Quality Assurance Privilege.”
An organizational culture that values the open discussion of potential problems, near misses, and errors without fear of retribution has been unequivocally demonstrated to be a core tenet of safety science and culture. Key historical examples include the famous Andon cord at Toyota manufacturing plants that allowed any employee, regardless of status, to stop the assembly line if a manufacturing defect was encountered.1 Another is the infamous O-ring failure that caused the space shuttle Challenger explosion, which showed the potentially tragic results of an organizational culture hostile to the open discussion of safety concerns.2 The O-ring was known to be problematic before the launch, but the engineers’ concerns were dismissed due to a strict hierarchal leadership structure at the National Aeronautics and Space Administration.
These and countless other examples emphasize the critical importance of maintaining an organizational culture that prioritizes the quality assurance and peer review process. The open, uncensored, and nonpunitive discussion of errors and problems is perhaps no more important than in health care.
As early as the 1910s, Ernest Codman introduced the concept of tracking the end results of a procedure as a measure of effectiveness and quality;3 this idea was instrumental to the birth of modern patient safety and quality improvement efforts, yet remains not fully realized more than a century later in modern US health care. In general, both the traditional morbidity and mortality conference as well as more modern methods of identifying, investigating, and understanding health care errors are foundational in promoting systems-based improvements in patient safety and the quality of health care delivery.
Unfortunately, our ability as physicians to review medical errors fully and openly with our peers is under attack. A recent ruling by the New York State Supreme Court, Appellate Division, Second Department, has led 1 major health care organization to curtail its peer review and quality assurance efforts.4
In November 2015, a man was struck by a car and sustained a head injury. The patient developed an intracranial hemorrhage and brain herniation, and subsequently died after being removed from life support. In December of that year, the case was discussed at the trauma peer review committee with 2 physician members of the patient’s health care team present….and then…..
REPRINTS & OTHER CORRESPONDENCE:
Vikas Mehta, MD, MPH, Department of Otorhinolaryngology—Head and Neck Surgery, 3400 Bainbridge Ave, 3rd Floor, MAP Building, Bronx, NY 10467
