Thursday, July 14, 2005

An excellent post on peer review, by Dr. Rangel.

I haven't had experience with being targeted by peer review malignantly, as Dr. Rangel described, but I was by a hospital administrator.

I have had a couple of interesting interactions with peer review, however. These, I think, were just sloppy, not malignant.

A companion of a patient I saw in the middle of the night complained about me. Now, these don't usually make it to peer review, but the allegations were significant enough that the medical services personnel forwarded it to peer review. The companion accused me of touching the patient, inappropriately, after she asked me to leave the room and of refusing to leave the room when requested and that the nursing supervisor had to be called to escort me out of the room. Now, none of this was true.

However, I didn't receive any request from the peer review to tell my side of this interaction. The first I knew that there was a complaint was a letter from the chairman of the peer review committee that they had reviewed the complaint and found that my behavior was inappropriate and that it should not be repeated.

I wrote to the commmittee chairman and expressed my disappointment that I was not allowed to provide any input to the committee. I also asked for an audience with the committee. I asked him what witnesses they had interviewed.

He answered that they had interviewed no witnesses. He said that the accusations were significant enough to warrant a warning to me and they didn't feel they need to investigate. I replied that the accusations were significant enough that, if true, they warranted disciplinary actions and, possibly, referral for criminal prosecution.

It would have been easy enough, I argued, simply to ask the nursing supervisor whether she had been called to escort me from the patient's room or to ask the nurse who was in the room with me whether I had touched the patient inappropriately.

After further investigation, I received a letter that stated that the committee had decided there was no support for the complaints. However, to avoid disturbing the complaintant, they never sent her a letter.

The other situation was when I used IM ketamine in a child in the ER without starting an IV first. I received a letter from the peer review that I had violated standard of care and that it was a level 3 occurrence. Of course, no one had asked my opinion before rendering this decision. My medical director had graded this a level 3 occurrence.

When I presented the chairman of the peer review committee with the abudance of literature that supported my use of ketamine, he referred me to my medical director. His comment was that I had violated the nursing policies and procedures for conscious sedation, but he agreed with my opinion regarding standard of care.

There is a huge difference between violating a nursing policy and a level 3 occurrence, violating standard of care. I received another letter of correction. However, the original letters censuring me remain in my peer review file. So the complaints could be "trended." If you trend bullshit, you get bullshit.