Adverse clinical event peer review must evolve to be relevant to quality improvement.

S elf-regulation is a defining hallmark and privilege of the medical profession. A fundamental component of self-regulation is peer review of adverse clinical events to support high-quality care. Peer review has been part of medical practice for centuries, with reports of its use in ancient Greece and 11th century Arabic medicine. 1 In the United States, peer review initially occurred as morbidity and mortality conferences. 2 By the mid-20th century, hospitals began forming peer review committees, not only for quality assurance but also to provide protection against malpractice litigation and to satisfy external regulation by licensure boards. 3,4 Unfortunately, both the culture and process of contemporary peer review can undermine its effectiveness in improving quality of care. Contemporary peer review often focuses on individual blame, causing many clinicians to view peer review as a personal affront. This can inhibit frank and open discussions about the root causes underlying the adverse event and potential strategies for improvement. This inhibition, in turn, may lead to systematic under-reporting of events. It may also contribute to reviewer bias, with many reviewers assuming that the mere presence of a review indicates individual wrongdoing or culpability. 5 This culture of individual blame is also at odds with the evidence that most adverse clinical events arise from system failures. The 1999 Institute of Medicine To Err is Human report emphasized that most adverse clinical events resulting in patient harm are not because of provid-ers' lack of competence, intentions, or hard work. 6 Rather, the system of care delivery is generally the root cause of most adverse events. The peer review process also has significant limitations that impede its ability to provide effective adjudication of events. Because most peer review is conducted at the local hospital level, it can be difficult to find reviewers with sufficient subject matter expertise and objectivity (ie, reviewers who do not work with the affected provider) to review cases. In addition , peer reviewers may lack sufficient training to review and identify the system deficiencies that often underlie complications. 2 Finally, hospitals rarely share the lessons learned from peer review with unaffected providers or other hospitals, and infrequently conduct adverse event trend analysis to assess provider and site rates of adverse events over time. Taken together, it is not clear that the culture and process of contemporary peer review meaningfully supports quality of care, and in some cases may hinder it. Fortunately, both …