Table 1 Descriptions of the 16 domains of care review

Systems analysis

Focused discussion on the role of the care system in the event being analyzed.

Functional department

The environment in which the care review process is deployed is in a position to receive the output from the review process and work toward implementation of change. There must also be buy-in from the stakeholders within the department (leadership, providers, nursing, ancillary staff).

Educational output

Process to create and disseminate lessons learned.

Standardized process

A clear flow of case identification and review that is consistently utilized.

Structured case classification

Consistent review process and inclusion of the same evaluations for all cases being discussed (e.g., use of a scaled rating system).

Feedback from and to the team

Individuals caring for patients who have had an adverse event are queried for their impressions and recollections of the incident, affording a glimpse of the decision-making process, and the state of the system at the time of the event. Following the review, they receive appropriate feedback regarding performance and systems issues to better understand all aspects to the event.

Human factor assessment

Contextual factors that affected decisions made by the care team are discussed in an effort to better understand the effects of the system on the individuals involved in the event.

Outcome consideration

The effect of the event on the patient is considered.

Non‐punitive

The review is explicitly and consistently identified as non-punitive and is not intended as a venue to mete out punishment to individuals for adverse events.

Recognition of excellence

Positive events during the event of care are identified and acknowledged.

Referral process

A voluntary referral process and/or an automated trigger (e.g., transfer to higher level of care) is available to identify cases for review.

Multidisciplinary

Inclusion of staff in a variety of roles (provider, nurse, etc.) in the review process to obtain multiple perspectives on the episode of care.

Process leadership

There are identified individuals to manage the process of care review consistently.

Reviewer training

Introductory explanation to reviewers of the ground rules of the process and how to think about the cases from appropriate perspectives (systems, care provided, team, human factors, etc.).

Case blinding

Cases are presented anonymously to minimize bias by reviewers.

Implementation of improvement recommendations

Care review group or committee is responsible for development and implementation of process improvement.