Peer case review sharpens event analysis.

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.