Team # 800 -- Peer Review of Adverse Events Process Team
Student Affairs

January 2006

Objective

The peer review project was initiated in 2006 to identify potential process improvements through the systematic peer review of any adverse event.

Team Membership

  • Nancy Lambert, Leader
  • Michelle Bonson, Member

Results Achieved to Date

  • ExpectedResults: The goal is to achieve completion of items in the action plan of the peer review within the timeline established in each action plan. Monitoring is ongoing.
  • Results from Nancy Lambert 7/14/09:

    Objective: The purpose of the study is to evaluate the initial and ongoing impact of a new process of adverse event reporting, peer review and plan of action for potentially adverse events that may occur at University Health Services (UHS).

    Evaluation of the previous process of risk management review of adverse events and “near miss” adverse events against benchmarking with the Agency for Heath Care Research and Quality (AHRQ), Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and AAAHC standards for review of adverse and/or sentinel events, revealed that the UHS process could be improved to better meet these standards.

    ExpectedResults: We measured the time frame from the date of the event peer review root cause analysis to completion of the items in the Action Plan. We have a goal of completion of all departmental items within five weeks of the peer review and interdepartmental items within 8 weeks of the review.
    Data collection and analysis was made for academic years 2007-2008 and 2008-2009. The sum of previous corrective measures from past monitoring activities have been successful.

    Corrective actions were:
    1) RCA group members are contacted monthly on the progress toward completion of the items on the Action Plans so that the dates of completion can be entered in the Action Plan.
    2) It was necessary to frequently repeat the message in staff meetings that the goal of reviewing adverse events is not to find fault with individuals; the focus is on process improvements to increase quality and decrease risk.
    3)Peer review RCA participants are asked to have action item discussions and educational activities documented in any meeting minutes so that it is clear when an action item is completed.

    Remeasurement was made during the same period in 2008-2009 to verify that the results were sustained. The project was completed in March 2009/

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Office of Planning and Institutional Assessment
The Pennsylvania State University
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