The Perils of “No Harm, No Foul” Peer Review Strategy


“As we discuss our peer review case screening criteria, some members of our peer review committee are adamant that we take a ‘no harm, no foul’ approach to our peer review program–that our focus should be only on cases with detrimental impact on the patient. Is this a reasonable strategy?”



It is quite common for hospitals to conclude that if a patient was not harmed, there was either no deviation from standard of care or the deviation was of little significance.

As part of MDReview’s own ongoing training and quality monitoring, we carefully evaluate every draft report to ensure that our peer reviewers do not equate standard of care with outcome. We feel it is unreasonable to rule out deviations from standard of care on the basis of an acceptable outcome or the absence of patient harm. Driving under the influence of alcohol is not acceptable regardless of whether or not someone is harmed. Similarly, poor clinical performance is not acceptable regardless of the outcome. The next time, someone could be harmed. We do not allow a reviewer to be critical of clinical practice and then conclude that standards of care have been met simply because the patient was not impacted by the deficiencies in care.

Likewise, adverse outcomes do not necessarily imply poor care. But, adverse outcomes should be a consideration for case screening even though the best of care can lead to undesired results. Effective quality management recognizes that monitoring systems should look not only for patient harm, but also for potential patient harm. The best quality management implements changes before anyone is harmed. Case screening criteria should be developed and employed regardless of patient impact or outcome.

Screening criteria must be sensitive to each specialty as well as to local characteristics. Widely used criteria for focused professional practice evaluation case selection includes, but is certainly not limited to, unexpected readmissions or returns to surgery, sentinel events, adverse patient outcomes, patient complaints, peer concerns, requests for new privileges, abnormal complication rates, unusual or disruptive behavior and aberrant utilization rates. While patient harm is an important consideration, the lack of patient harm should not exclude cases from peer review.

A “no harm, no foul” approach diminishes the quality improvement potential your peer review program holds for your organization and those it serves.