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case review, peer case review, peer review, quality of care, root cause analysis



  1. Hitchings, Kim S. MSN, RN, NEA-BC
  2. Davies-Hathen, Nancy MSN, MEd, RN, NEA-BC
  3. Capuano, Terry Ann MSN, MBA, RN, NE-BC
  4. Morgan, Georgiann RN
  5. Bendekovits, Rita MSN, RN, ONC, CRRN


This manuscript describes a scholarly approach to peer case review that identifies and analyzes quality-of-care issues in response to a question about nursing care of a specific patient. The comprehensive method provides a structured format that critically examines untoward patient events, generates an awareness of gaps in care from a systems perspective, ensures action planning focused on legitimate root causes, stimulates performance improvement initiatives, and provides a forum to share learning throughout the organization.