NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

1

Implementation of Post-Fall Nursing Peer Reviews to Improve Patient Safety Culture

Lindsay M. Blythe
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Lindsay M. Blythe is a registered nurse in an inpatient nursing department.
She has no known conflicts of interest to disclose.
Correspondence should be addressed to Lindsay M. Blythe, Edson College of Nursing
and Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix,
AZ 85004. Email: lblythe1@asu.edu

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

2

Abstract
Falls in hospitalized patients are a widespread occurrence in the United States, resulting in
unfavorable outcomes amongst patients, healthcare providers, and hospital organizations.
Current fall prevention efforts have failed to adequately reduce patient fall rates. Nursing peer
review (NPR) seeks to refine the quality and safety of patient care, making its use applicable in
post-fall reviews. This evidenced-based quality improvement project implements a post-fall NPR
program to examine patient falls in an inpatient setting, in addition to the facilitation of patient
safety culture education. The Hospital Survey on Patient Safety Culture was used to assess
nurses’ perceptions of their units’ patient safety culture. The pre- and post-survey results were
analyzed using a two-tailed Mann-Whitney U test, determining significant differences in event
(U=2033, z=-2.81, p=.005) and learning (U=1196, z=-2.52, p=.012). No significant differences
were noted in support (U=1587, z=-0.05, p=.959), prevent (U=1369, z=-0.70, p=.485), and rate
(U=1355.5, z=-0.34, p=.737). Post-fall NPR participation survey results were analyzed using
descriptive statistics, showing that it improved patient safety culture (n=10, 91%), reduced
“blame & shame” culture (n=9, 82%), and was a non-punitive learning method (n=10, 91%).
Reviewing falls through NPR and educating nurses on patient safety culture can create a positive
environment to learn from falls. Additional research is needed to determine the impact on patient
fall rates.
Keywords: patient fall, fall prevention, inpatient, nurse, peer review, patient safety
culture, Just Culture

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

3

Implementation of Post-Fall Nursing Peer Reviews to Improve Patient Safety Culture
As patient care in today’s healthcare system becomes more complex, the overarching
goal remains to provide high-quality, safe patient care. Despite this aim, adverse events continue
to plague hospitals, creating undue harm to patients. One adverse event in particular, patient
falls, occurs at prevalent rates in hospitals. Falls create detrimental consequences to both patients
and hospitals, supporting the need to conduct a thorough literature review, to gather evidencedbased knowledge emphasizing patient falls.
Problem Statement
It is imperative to understand the definition of a patient fall, creating a clear perception of
what classifies a fall in the hospital setting. Press Ganey (2020), the National Database of
Nursing Quality Indicators’ program director, defines a patient fall as:
A sudden, unintentional descent, with or without injury to the patient, that results in a
patient coming to rest on the floor, on or against some other surface (e.g., a counter), on
another person, or on an object (e.g., a trash can). (p. 2)
The Agency for Healthcare Research and Quality (AHRQ, 2018) reports that 700,000 to
1,000,000 hospitalized patients fall per year in the United States. The Joint Commission (2015)
reports that 30-50% of patient falls result in injury. Most recently, a retrospective chart analysis
of 2,299 inpatient falls over a five-year period discovered that 46.9% of falls resulted in patient
injury (Trinh et al., 2020). Consequently, falls increase the length of hospital stays and create
additional healthcare expenditures. The Joint Commission (2015) estimates that falls lengthen
hospital stays by 6.3 days and cost $14,000 per fall with injury.
Purpose and Rationale

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

4

Given the prevalence of patient falls, this evidenced-based practice synthesis seeks to
understand current fall prevention interventions and post-fall review protocols that are
implemented in the hospital setting. More precisely, it seeks to better understand interventions
that are tailored to nursing staff, assessing their effectiveness in reducing patient falls.
Additionally, literature regarding patient safety culture will be obtained, to determine its impact
on patient outcomes. Ultimately, evidenced-based knowledge will be identified that seeks to
prevent future patient falls.
Background and Significance
Adult Inpatient Units
The Joint Commission (2021) lists falls as a preeminent sentinel event reported to their
organization. A fall is considered a sentinel event if it results in:
Any fracture; surgery, casting, or traction; required consult/management or comfort care
for a neurological (e.g., skull fracture, subdural or intracranial hemorrhage) or internal
(e.g., rib fracture, small liver laceration) injury; a patient with coagulopathy who receives
blood products as a result of the fall; or death or permanent harm as a result of injuries
sustained from the fall (not from physiologic events causing the fall). (Joint Commission,
2021, p. 4)
The mean age of patients falling in the hospital is 52.9 to 61.5 years old (Kobayashi et al.,
2017; Najafpour et al., 2019; O’Neil et al., 2018). Risk factors associated with falling in the
hospital include cognitive impairment, gait difficulties, incontinence, and lengthy hospital stays
(Najafpour et al., 2019; O’Neil et al., 2018). Additionally, certain medications can increase
patients’ risk for falling. These medication classes include benzodiazepines, antipsychotics,

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

5

antidepressants, antihypertensives, and diuretics (de Vries et al., 2018; Najafpour et al., 2019;
O’Neil et al., 2018).
Nursing Peer Review
As patient falls will inevitably occur, it is imperative for hospitals to engage in a process
to examine the fall and to determine methods for successful fall prevention. The Joint
Commission (2015) and AHRQ (2018) recommend the use of post-fall reviews to reduce patient
falls. Debriefing after patient falls allows those involved to learn from the incident, therefore
generating knowledge that can be spread to others to prevent future falls from reoccurring.
Clinical peer review is a presiding method used to analyze such events, aiming to improve the
quality and safety of patient care, as noted in Edwards’ (2018a) 8-year longitudinal study of its
use in United States hospitals. As this evidenced-based synthesis targets nursing staff
specifically, a post-fall nursing peer review method will be examined.
Nursing peer review (NPR) was initially created by the American Nurses Association
(ANA, 1988) to enhance the quality of nursing care. The guiding principles of NPR include that
it: must occur between nurses of the same rank; is practice-focused; occurs in a timely and
frequent manner; promotes a learning culture that is dedicated to patient safety and evidencedbased practice; is not anonymous; takes into consideration nurses’ current developmental stages
(ANA, 1988). George and Haag-Heitman (2015) further refined NPR based on the ANA’s
recommendations, creating an accountability-focused nursing framework to guide the process.
Essential components include a responsive and safe learning environment, management support,
shared leadership practices, and nurse empowerment (George & Haag-Heitman, 2015).
NPR enhances professional growth and development amongst nursing, strengthening the
care that they provide to their patients (Bowen et al., 2019; Herrington & Hand, 2019).

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

6

Currently, limited research exists on the use of NPR to improve specific patient outcomes. Its
intent is to improve patient care through adverse event review, making it applicable to patient
falls, a widely prevalent adverse event in hospitals. Roberts and Cronin’s (2017) descriptive
study assessed NPR programs in 66 hospitals in the United States, concluding that further
research is needed to determine the impact of NPR on specific measurable outcomes, supporting
this objective to understand its effect on patient safety culture and inpatient fall rates.
Fall Prevention and Post-Fall Review
Turner and colleagues (2020) conducted a cross-sectional descriptive study to discern the
current fall prevention interventions that are implemented in 60 hospitals across the United
States. Although 90% of these hospitals are located in urban population centers, the hospitals’
bed-capacities varied, increasing heterogeneity in the study sample. Additionally, 53% of the
hospitals were certified. Each hospital in the study had a method for setting fall expectations,
whether it be through fall policies (98%), reporting falls in annual hospital reports (95%), or
rewards for top-performing units (40%). Fall prevention committees were utilized in 83% of the
hospitals, providing resources and education within their organizations to decrease patient falls.
Lastly, every hospital provided fall prevention education during new-staff orientation, although it
was not always provided on an annual basis (Turner et al., 2020).
The AHRQ (2018) details safety huddles in their fall prevention toolkit. A safety huddle
is defined as a, “short, informal meeting to cover issues related to patient safety” (AHRQ, 2018,
p. 44). When a patient fall occurs, a post-fall huddle can be completed immediately, to identify
potential causes of the fall and methods to prevent future falls (AHRQ, 2018). Jones and
colleagues (2019) conducted a longitudinal study in 16 hospitals to analyze the influence of postfall huddles on fall rates and safety culture. Results showed that post-fall huddles may decrease

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

7

repeat fall rates, as well as create more positive impressions of their hospitals’ safety culture
(Jones et al., 2019).
Although the intent of these interventions is to reduce patient falls, there is the potential
for them to create negative consequences. One qualitative descriptive study sought to understand
their influence on nurses and the care that they provide to fall-risk patients (King et al., 2016).
The intense pressure to prevent falls created a culture of blame and shame, causing nurses to be
fearful of falls. This fear led to the overidentification of fall risk patients and the overuse of
alarms, which unnecessarily restricted patient movement and worsened patient outcomes (King
et al., 2016). Bed alarms are used too frequently, are often ineffective, and create a false sense of
security amongst nurses and patients (LeLaurin & Shorr, 2019; Staggs et al., 2020)
Patient Safety Culture
NPRs should be objective and nonjudgmental, enhancing nurses’ accountability and
responsibility (Herrington & Hand, 2019). Through appropriate NPR implementation, its use has
been shown to improve the quality of patient care and reinforce a culture of patient safety
(Herrington & Hand, 2019; Korkis et al., 2019). Just Culture concepts are relevant to topic of
patient safety culture. According to the ANA (2015), Just Culture is:
An organizational environment that holds individuals accountable for performing duties
of avoiding harm, producing outcomes and following policies, procedures or guidelines
that: recognizes individuals choose and need to manage human error, at-risk behaviors
and reckless behaviors; recognizes individuals make mistakes and systems fail; learns
from mistakes, treat individuals fairly; coaches to avoid risky behaviors; and disciplines
reckless or knowingly dangerous behaviors. (pp. 43-44)

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

8

To facilitate a Just Culture within an organization, it requires strong leadership that
encourages open, honest, and teamwork-centered communication (Barkell & Snyder, 2021;
O’Donovan et al., 2019). While it is imperative to hold individuals accountable for adverse
events such as a patient fall, a culture of blame should be avoided. A Just Culture represents a
nonpunitive environment, in which individuals can feel safe to report errors (Barkell & Snyder
2021; Edwards, 2018b; O’Donovan et al., 2019; White & Delacroix, 2020). Furthermore, it
supports a positive response to errors that do occur, allowing individuals to learn from the
incident (White & Delacroix, 2020). Application of NPRs can be an integral component of this
safety culture, allowing nurses to safely identify what could be improved in patients’ care.
Ideally, their implementation will improve patient safety culture and lead to a reduction in
patient fall rates.
Patient falls remain an extensive issue in today’s healthcare system, creating unfavorable
outcomes for patients and hospital organizations. Post-fall reviews are recommended, seeking to
identify factors that contribute to patient falls and to disseminate those findings to prevent future
falls. NPR is an applicable approach to guiding post-fall reviews, as its aim is to improve patient
care. Currently, hospital organizations provide extensive education to nurses regarding patient
falls, which can conversely cause nurses to be fearful of falls and negatively impact their patient
care. NPR can improve this education process, by providing relevant and nonpunitive feedback,
in order promote a safety culture that is committed to decreasing patient falls.
Internal Evidence
A 268-bed adult inpatient hospital, located in metropolitan Arizona, has identified patient
falls as a top safety risk. Extensive fall prevention strategies have been employed throughout the
organization. Despite their efforts, inpatient falls continue to occur at high rates. The

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

9

organization reports 567 inpatient falls from 2017 to 2020, with 159 (28%) of the falls resulting
in injury to the patient. Of most importance is the harm to patients, although the financial
consequences to the organization are relevant as well. The Centers for Medicare and Medicaid
Services (CMS, 2020) categorizes falls as hospital-acquired conditions, in which they do not
accept financial responsibility for fall-related costs, creating potentially avoidable expenditures
to the hospital organization. Using the Joint Commission’s (2015) estimate that each fall with
injury costs $14,000, using the 159 inpatient falls that resulted in injury at this project site,
hypothetically it would have created 2.23 million in costs that were not reimbursed if these falls
occurred in patients receiving CMS benefits.
Through support of the organization, current evidence was gathered to determine
effective fall prevention interventions. This literature review has led to the clinically relevant
PICOT question, “In adult inpatient nurses (P), how do post-fall nursing peer reviews (I),
compared to current post-fall review protocols (C), affect their perception of patient safety
culture (O) within 16 weeks (T)?”
Search Strategy
A thorough review of the literature was conducted utilizing the PICOT question to guide
the scholarly search process. The databases used included Academic Search Premier, CINAHL,
and PubMed. Relevant keywords were chosen to accurately reflect the PICOT and to strengthen
the search results. Inclusion criteria limited search results to English language, research articles,
and publication between 2015-2021. Exclusion criteria included publications prior to 2015, those
not available in English language, and non-healthcare related research. Additionally, a grey
literature search was performed, deriving regulatory data, government publications, and policy

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

10

statements. Applicable research articles obtained from the search underwent rapid critical
appraisal, leading to the extensive evaluation of 10 studies to be used for this project.
Academic Search Premier
The keywords nurse, peer review, and patient fall were searched, yielding no results. The
keywords peer feedback, peer evaluation, hospital, inpatient, adverse event, and incident were
added and combined with Boolean connectors to yield 218 results. Adding the keywords root
cause analysis, after-action review, and adverse event review then produced 42 results for indepth review. Additionally, keywords Just Culture, patient outcome, adverse event, incident, and
patient safety were searched, deriving 29 results to be reviewed.
CINAHL
The keywords nurse, peer review, and patient fall were searched, yielding no results. The
keywords peer feedback, peer evaluation, peer-to-peer, and after-action review were added,
resulting in 2,216 results. To further refine the search, keywords hospital, inpatient, adverse
event, and incident, were added and combined with Boolean connectors to yield 218 results.
Keywords sentinel event and patient outcome were included, producing 52 results for in-depth
review. Lastly, a search with Just Culture, patient outcome, adverse event, incident, and patient
safety keywords was conducted, yielding 45 results to be reviewed.
PubMed
The keywords nurse, peer review, and patient fall were searched, yielding 3 results. The
keywords peer feedback, peer evaluation, peer-to-peer, after-action review, hospital, inpatient,
adverse event, sentinel event, incident, and outcome were added and combined with Boolean
connectors to yield 278 results. Additional keywords, root cause analysis, adverse event review,
and quality of care, resulting in 89 results for in-depth review. A supplemental search was

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

11

conducted, utilizing Just Culture, patient outcome, adverse event, incident, and patient safety as
key words, providing 49 results to be reviewed.
Critical Appraisal and Synthesis of Evidence
Rapid critical appraisal (RCA) of the literature was conducted, utilizing Melnyk and
Fineout-Overholt’s (2019) RCA process. Although NPR is recommended by the ANA, its use
has not been heavily studied. Of the relevant literature, a combination of qualitative (see
Appendix A, Table A1) and quantitative (see Appendix A, Table A2) were obtained, and further
evaluated in a synthesis table (see Appendix A, Table A3). These studies do in fact represent low
levels of evidence, yet their outcomes and themes effectively describe the benefits of NPR
phenomena, making them applicable to this literature review.
Each study was conducted in an inpatient setting, with 90% occurring in United States
hospitals. Further heterogeneity was displayed in the hospitals’ variable bed capacities. The
number of study participants were generally low, although this is to be expected given the low
levels of evidence and limited research in this field. Three studies provided a detailed
understanding of current fall prevention measures utilized in hospitals, concluding that more
research is needed to discover methods to reduce patient falls. Additionally, three studies
thoroughly described qualitative themes, including NPR’s facilitation, barriers, lessons learned,
and benefits, to better understand NPR integration. Furthermore, improved nurse satisfaction
scores were shown in three NPR studies. Although not NPR-specific, two studies reported
enhanced Just Culture adaption and refined quality improvement scores using clinical peer
review.
Influence of Evidence

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

12

Despite the abundance of fall prevention efforts employed by hospital organizations,
alarmingly high rates of patient falls continue to occur. The successful implementation of postfall reviews is critical to learn from these adverse events and to prevent more falls from
occurring in the future. A standardized approach for this process does not exist, calling for
additional research to generate new evidence-based knowledge regarding post-fall reviews. NPR
proves to be effective in improving patient care by empowering and educating nurses, yet more
needs to be known regarding its ability to affect specific patient outcomes. Its use in post-fall
reviews is intriguing, with the feasible potential to create a patient safety culture environment
that prevents future patient falls.
Theory Application
George and Haag-Heitmann’s (2015) accountability-focused theoretical framework
fosters a culture that enhances the quality and safety of patient care. The framework’s four
concepts previously mentioned; a responsive environment, management, shared leadership
development, and personal empowerment, are all essential to the facilitation of successful fall
prevention. More specifically, NPR is a subcomponent of personal empowerment, ultimately
enabling nurses to feel equipped to provide safe patient care. When combined with the
framework’s other concepts, ample behavioral change will be achieved to allow for improved
nurse autonomy and accountability, inherently leading to an improvement in the quality and
safety of patient care (George & Haag-Heitmann, 2015).
The structure of this project was created with this theoretical framework in mind.
Through implementation of post-fall NPR, nurses will be held accountable for their care and will
become more knowledge regarding fall prevention. Post-fall NPR incorporates shared leadership
concepts through the facilitation of teamwork-centered communication. Additionally,

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

13

encouraging honest and open-ended discussions regarding patient falls enhances personal
empowerment amongst nurses. A commitment to post-fall NPR creates a safe learning
environment, in which patient safety becomes a priority. Lastly, this intervention has support
from management, an essential component to improve their units’ patient safety cultures.
Implementation Framework
The project site’s evidenced-based practice model was utilized throughout the creation
and implementation of this project. This model is the cornerstone process used to guide nursing
evidenced-based practice projects at the selected organization. It includes seven steps; formulate
a question, search for evidence, appraise the evidence, compare and contrast, decision options,
evaluate, and disseminate. The organization identified patient falls as a top safety risk, lending
itself to a relevant PICOT question, literature review, and critical appraisal, discerning the
applicability of NPR in post-fall reviews.
According to stakeholders within the organization, post-fall NPR is a process that is
currently being facilitated on two inpatient units. The organization has expressed interest in
incorporating this practice on two additional inpatient units to gain more knowledge on its effect
on patient safety culture and inpatient fall rates. Through extensive collaboration with the key
stakeholders, an intervention was created. Outcome measures were further agreed upon, lending
support to conduct this evidence-based quality improvement project. At the completion of the
project, the results were disseminated across the organization.
Methods
Intervention
This evidence-based quality improvement project was conducted on two inpatient units,
an intermediate care unit and a cardiovascular progressive care unit. These units represent similar

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

14

high-acuity patient populations, with a large prevalence of inpatient falls. The intervention
targets inpatient nursing staff, whom are at the forefront of patient care and are most frequently
involved in patient falls. Their perceptions of their units’ patient safety culture were assessed, in
addition to receiving education regarding post-fall NPR, patient safety culture, and inpatient fall
prevention.
The intervention was piloted over 16 weeks, which included two weeks of gathering presurvey data, 12 weeks of education and post-fall NPR implementation, and two weeks of
gathering post-survey data. Falls create physical, emotional, and financial consequences to
patients, healthcare providers, and healthcare organizations. This intervention seeks to improve
the patient safety culture on each pilot unit, creating an environment where falls are freely
discussed and learned from, with the future potential to determine its long-term impact on
inpatient fall rates within this healthcare organization.
Fall Committee Education
Each pilot unit had a fall committee in place, consisting of a total of 24 nurses. These
groups expressed the interest in incorporating post-fall NPR into their practice. Before the
implementation of post-fall NPRs could begin, fall committee members needed to be educated
on the process and its potential to impact the patient safety culture on their units. Three
educational opportunities were provided to the fall committee members, in the form of a onehour Zoom meeting. If a nurse was unable to attend one of these sessions, the educational
material was sent to their workplace email. Educational tools utilized during this meeting
included a PowerPoint presentation discussing internal fall data, post-fall NPR, and patient safety
culture. Additionally, fall chart auditing was explained, utilizing the organization’s electronic

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

15

medical record training environment. This training environment allowed fall committee members
to familiarize themselves with chart auditing, without the use of protected health information.
Post-Fall NPRs
The post-fall NPRs were facilitated during monthly fall committee meetings. These onehour meetings occurred over Zoom and were scheduled in advance for the third Monday of each
month, to increase convenience for fall committee members. Both pilot units’ fall committees
were in attendance. Nurses involved in patient falls were also invited to participate by the
project’s Co-Investigator. If these nurses worked on the unit during these meetings, nursing
management from each pilot unit agreed to provide patient coverage to allow the nurses to
participate.
As patient falls occurred on each pilot unit, nursing management would promptly send
the fall documents to the fall committee chairs. Two to three fall committee members per patient
fall were assigned a post-fall NPR and were provided with the applicable fall documents. These
documents were used to complete a chart audit, providing reviewers with relevant information to
complete the post-fall NPR form. This form was created by the project site, assessing patients’
fall risk factors, vital sign trends, and fall precaution measures that were in place prior to the fall.
This protected health information was de-identified by peer reviewers prior to the fall committee
meeting and was not visible to the project’s Primary Investigator and Co-Investigator.
The format of the fall committee meetings was centered around the completed post-fall
NPRs. To begin, peer reviewers shared their completed post-fall NPR forms. If the nurse
involved in the fall was present, they were given the opportunity to discuss the event. This
allowed for open, informal, and non-punitive dialogue amongst those in attendance. Information
generated during this discussion was used to complete the falls peer review group summary and

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

16

recommendation form. Each fall took approximately 10 to 15 minutes to review. For any
additional meeting time remaining, fall committee members collaboratively discussed current
fall prevention methods on their units and brainstormed future fall prevention strategies.
Pilot Unit Education
Throughout the 12-week post-fall NPR implementation, education was provided to
inpatient nurses on each pilot unit, which consists of approximately 250 nurses. These
educational sessions occurred during four, in-person professional development day meetings, as
well as two, Zoom unit-based team meetings. These meetings are a mandatory job requirement
for inpatient nurses on each pilot unit, allowing this project’s education to be integrated into
these pre-scheduled meetings, therefore reflecting it not to be an additional requirement for
participants. Closely matching the education provided to the fall committees, a brief PowerPoint
presentation was given to discuss internal fall data, post-fall NPR, and patient safety culture.
Ethical Considerations
Prior to this project’s implementation, project site approval was obtained. Furthermore,
approval was received from the Arizona State University Institutional Review Board on July
29th, 2021 (see Appendix B). To maintain participant privacy, no personal identifying
information was obtained, in which survey responses could not be directly linked to project
participants. Survey data was safeguarded through the project site’s secure server and a password
encrypted computer. This data will be stored for a year after the project’s completion date, at
which it will then be permanently deleted. Access to these files will be limited to the project’s
Primary Investigator and Co-Investigator. Lastly, as mentioned above, protected health
information that was used to complete the post-fall NPRs were deidentified prior to fall

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

17

committee meetings and were not available to the project’s Primary Investigator and CoInvestigator.
Participants
The participants in this evidence-based quality improvement project include inpatient
nurses on two pilot units. Approval from project site leadership was obtained to include this
sample as participants in the project. Recruitment emails were sent by the project’s CoInvestigator to the participants’ workplaces emails, prior to survey distribution and as an
invitation to attend the post-fall NPR if involved in a patient fall. A total of 24 inpatient nurses
were members of the fall committees that completed the post-fall NPRs. The pilot unit education,
as well as the pre- and post- surveys, were given to approximately 250 inpatient nurses.
Exclusion criteria included nursing supervisors and managers. This sample did not include
special populations: minors under the age of 18, adults who are unable to consent, prisoners, and
economically or educationally disadvantaged individuals.
Instruments
Hospital Survey on Patient Safety
The AHRQ’s (2019a) Hospital Survey on Patient Safety was used as a pre- and postsurvey in this project (see Appendix C, Figure C1). This 40-item Likert-scale survey is free and
available for public use. It was measured for validity using pilot test data from 25 hospitals and
4,345 hospital staff members across the United States (AHRQ, 2019b). The survey’s items are
grouped into 10 composite measures, all confirmed for reliability using Cronbach’s alpha, with a
domain range of 0.67 to 0.89 (AHRQ, 2019b). A high mean response to a survey item indicates
that more nurses agree with the statement, while a low mean response indicates that more nurses
disagree with the statement. Assessing nurses’ perceptions of their units’ patient safety culture

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

18

aligns with the project’s theoretical framework, as this environment can improve the quality and
safety of patient care, potentially impacting future inpatient fall rates.
Post-Fall Nursing Peer Review Survey
An additional post-fall NPR participation survey (see Appendix C, Figure C2) was
created by the project’s Co-Investigator. This survey was administered to fall committee
members and nurses involved in patient falls who participated in the post-fall NPRs. Given that
its validity and reliability could not be confirmed, it was reviewed by the project’s Primary
Investigator for its content and face validity. This six-item Likert-scale survey assessed
participants’ perceptions of post-fall NPRs’ impact on nurse autonomy, accountability, and job
satisfaction, as well as its influence on a patient safety culture versus a blame and shame culture.
Participants’ beliefs on whether post-fall NPR is a non-punitive response to error were also
assessed. An additional open-ended question was included at the end of the survey to determine
how post-fall NPRs could be improved, to refine the process and to assist the project site to
potentially implement this intervention hospital-wide in the future.
These surveys were created using REDCap, the preferred web application for
administering online surveys at the project site. The project’s Co-Investigator was responsible
for emailing each survey to inpatient nurses’ workplace emails, to be completed by participants
during their paid work shifts. A consent statement was included at the beginning of each survey.
By responding “yes” to this statement, consent to participate was obtained, directing the
participants to complete the survey. Demographics collected in each of these surveys included
the nurses’ age range, number of years as a nurse, number of years at the project site
organization, highest level of education, and nurse certification status.
Data and Budget

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

19

Survey data was inputted into Intellectus Statistics statistical software. In accordance with
recommendations from Intellectus statisticians, this data was further analyzed using descriptive
statistics and a two-tailed Mann-Whitney U test, to describe the participant sample and to
determine meaningful outcome variables from each survey. No grants or financial aid were
attained for this project. All associated costs for project development and implementation were
incurred by the project site and the project’s Co-Investigator (see Appendix D).
Results
Demographic Data
Descriptive statistics were used to describe the surveys’ samples. Eighty-one participants
completed the Hospital Survey on Patient Safety pre-survey. The most frequently observed age
range was 20 to 29 years old (n=35, 43%), years as a nurse was 1 to 4 years (n=30, 37%), years
at the organization was 1 to 4 years (n=47, 58%), and highest level of education was a Bachelor
degree (n=61, 75%). Thirty-nine participants completed the Hospital Survey on Patient Safety
post-survey. The most frequently observed age range was 20 to 29 years old (n=18, 46%), years
as a nurse was 1 to 4 years (n=15, 38%), years at the organization was 1 to 4 years (n=20, 51%),
and highest level of education was a Bachelor degree (n=27, 69%). Eleven participants
completed the post-fall NPR survey. The most frequently observed age range was 50 years or
older (n=4, 36%), years as a nurse was 5 to 9 years (n=3, 27%) 10 to 14 years (n=3, 27%), or 15
years or more (n=3, 27%), years at the organization was 5 to 9 years (n=8, 73%), and highest
level of education was a Master or doctorate degree (n=6, 55%).
Outcomes
Hospital Survey on Patient Safety

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

20

Pre-survey (n=81) and post-survey (n=39) data were analyzed using a two-tailed MannWhitney U test, to determine if there were statistically significant differences in survey responses
from the two independent groups, based on an alpha of .05. The results of the two-tailed MannWhitney U test was significant for event (U=2033, z=-2.81, p=.005). The mean rank for the presurvey was 66.10 and the mean rank for the post-survey was 48.87. The lower mean rank score
suggests that the intervention significantly decreased nurses’ beliefs that a reported event feels
like the person is being written up, not the problem. Additionally, the results were significant for
learning (U=1196, z=-2.52, p=.012). The mean rank for the pre-survey was 55.77 and the mean
rank for the post-survey was 70.3. The higher mean rank score suggests that the intervention
significantly increased nurses’ beliefs that their unit focuses on learning rather than blaming
individuals. The results were not significant for support (U=1587, z=-0.05, p=.959), prevent
(U=1369, z=-0.70, p=.485), and rate (U=1355.5, z=-0.34, p=.737). Given that there were no
statistically significant changes in mean rank scores, it suggests that the intervention had no
impact on nurses’ beliefs regarding the support for staff involved in patient safety errors,
preventative discussions after errors occur, and their units’ patient safety ratings.
Post-Fall Nursing Peer Review Survey
Seven inpatient falls underwent a post-fall NPR during project implementation.
Participation survey (n=11) data was analyzed using descriptive statistics, to examine and
summarize nurses’ experiences in post-fall NPR participation. Post-fall NPR improved patient
safety culture (n=10, 91%), reduced blame and shame culture (n=9, 82%), and was a nonpunitive learning method (n=10, 91%). Regarding its impact on nurses, it improved their
autonomy (n=9, 82%), accountability (n=11, 100%), and job satisfaction (n=6, 55%).
Clinical Significance

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

21

Given the statistically significant improvements in nurses’ beliefs that a reported event
concentrates on the problem itself and that their units focus on learning rather than blaming
individuals, a vast number of positive clinical outcomes may be seen. In alignment with this
project’s goals, a reduction in patient falls would ideally occur. Enhancing the units’ patient
safety culture, as shown in the results from the post-fall NPR participation survey, may create a
culture that safely discusses all adverse events (ie: medication errors, hospital-acquired
conditions, etc.). As adverse events cannot be entirely avoided in healthcare, a positive response
to these events is integral to prevent them from occurring in the future.
Project Impact
Enhancing patient safety culture using post-fall NPR creates a unit committed to inpatient
fall prevention. It promotes a non-punitive learning environment, allowing for falls to be freely
discussed and learned from. Reducing nurses’ feelings of blame and shame after a fall can
facilitate a safe environment, producing meaningful fall prevention discussions. Ultimately, this
environment may lead to a reduction in patient falls, improving outcomes for patients, healthcare
providers, and hospital organizations.
Sustainability
This evidence-based quality improvement project was created with sustainability in mind.
Previously, the project site had implemented post-fall NPR on two inpatient units, with a goal to
implement it hospital-wide. This project provides additional knowledge on the benefits of postfall NPR, as well as opportunities for improvement, to enhance the process and to encourage
nurse participation in the future. The project site is committed to creating a patient safety culture
that discusses adverse events in a non-punitive manner. Given the intervention’s potential to

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

22

reduce patient falls and the associated financial consequences, it is likely cost-effective to
continue the post-fall NPR program.
Discussion
Summary
This evidence-based quality improvement project determined that post-fall NPR
enhanced patient safety culture, while reducing a blame and shame environment. Additionally,
participants agreed that it was a non-punitive learning method. These findings are in accordance
with the current evidence-based literature (Barkell & Snyder, 2021; Edwards, 2018b; Herrington
& Hand, 2019; Korkis et al., 2019; O’Donovan et al., 2019; White & Delacroix, 2020).
Additional knowledge garnered from this project include an improvement in nurses’ beliefs that
their units focus on learning from adverse events after they occur, rather than blaming the
individuals involved in the incident.
Strengths and Limitations
The creation and implementation of this evidence-based quality improvement project
were strengthened by the project site’s stakeholder support. This organization is Magnet®
recognized, in which this project’s goals to improve patient safety culture directly align with
Magnet’s nursing excellence values. Each unit had fall committees in place, consisting of nurses
committed to patient safety and fall prevention. This allowed for seamless integration of the
post-fall NPR and educational interventions. Additionally, these interventions could be
facilitated through Zoom, increasing the convenience for the project’s participants. Furthermore,
a large sample size was obtained, allowing for meaningful conclusions to be drawn.
Limitations include that the project’s outcomes were dependent on real-time falls
occurring. The project’s short 16-week time frame was a hindrance, in that the project was near

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

23

completion as the participants expressed more comfortableness with the post-fall NPR process. It
was also determined that the chart audits needed to complete the post-fall NPR form were time
consuming. When reviewing the post-fall NPRs at fall committee meetings, limited participation
from the nurses involved in the falls were noted. This hesitation may be attributed to a fear to
participate, potentially due to inadequate post-fall NPR and patient safety culture education.
Lastly, this project was implemented during the COVID-19 pandemic, in which the project site’s
resources were heavily allocated towards relief efforts.
Recommendations
This evidence-based quality improvement project determined that a post-fall NPR
program enhanced patient safety culture on two inpatient units, therefore reducing a blame and
shame environment. Post-fall NPRs were viewed as a non-punitive method to learn from patient
falls, creating relevant recommendations and encouraging fall prevention discussions. This
project did not assess patient falls rates, given its short time frame. To determine its impact on
inpatient falls, a longitudinal study is recommended to analyze trends in fall rates.
To improve the post-fall NPR process, an integration of the applicable incident forms and
fall documentation into a single location within the electronic medical record is recommended.
The chart audits were deemed as time consuming, creating challenges in promptly and
thoroughly completing the post-fall NPR forms. Additionally, more education must be facilitated
to inpatient nurses, reducing their potential fear to participate. To best learn from a patient fall,
the input from the nurse involved is invaluable. Creating an environment where nurses feel safe
to freely discuss and learn from falls is instrumental, ultimately improving outcomes for patients,
healthcare providers, and hospital organizations.

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

24

References
Agency for Healthcare Research and Quality. (2018). Preventing falls in hospitals: A toolkit for
improving quality of care.
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
Agency for Healthcare Research and Quality. (2019a). Hospital Survey on Patient Safety
(Version 2.0).
https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPSHospital-Survey-2.0-5-26-2021.pdf
Agency for Healthcare Research and Quality. (2019b). SOPS hospital survey items and
composite measures.
https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2items.pdf
American Nurses Association. (1988). Peer review guidelines. American Nurses Association.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.
American Nurses Association.
Barkell, N. P., & Snyder, S. S. (2021). Just culture in healthcare: An integrative review. Nursing
Forum, 56, 103-111. https://doi.org/10.1111/nuf.12525
Bowen-Brady, H., Haag-Heitman, B., Hunt, V., & Oot-Hayes, M. (2019). Asking for feedback:
Clinical nurses’ perceptions of a peer review program in a community hospital. Journal of
Nursing Administration, 49(1), 35-41. https://doi.org/10.1097/NNA.0000000000000705

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

25

Centers for Medicare and Medicaid Services. (2020). Hospital-acquired conditions.
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/Hospital-Acquired_Conditions
de Vries, M., Seppala, L. J., Daams, J. G., van de Glind, E., Masud, T., & van der Velde, N.
(2018). Fall-risk-increasing drugs: A systematic review and meta-analysis: 1.
cardiovascular drugs. Journal of the American Medical Directors Association, 19(4),
Article 371. https://doi.org/10.1016/j.jamda.2017.12.013
Edwards, M. T. (2018a). In pursuit of quality and safety: An 8-year study of clinical peer review
best practices in US hospitals. International Journal for Quality in Health Care, 30(8),
602-607. https://doi.org/10.1093/intqhc/mzy069
Edwards, M. T. (2018b). An assessment of the impact of Just Culture on quality and safety in US
hospitals. American Journal of Medical Quality, 33(5), 502-508.
https://doi.org/10.1177/1062860618768057
George, V., & Haag-Heitman, B. (2015). Peer review in nursing: Essential component of a
model supporting safety and quality. Journal of Nursing Administration, 45(7/8), 398403. https://doi.org/10.1097/NNA.0000000000000221
Herrington, C. R., & Hand, M. W. (2019). Impact of nurse peer reviews on a culture of safety.
Journal of Nursing Care Quality, 34(2), 158-162.
https://doi.org/10.1097/NCQ.0000000000000361
Joint Commission. (2015, September 28). Sentinel event alert 55: Preventing falls and fall-related
injuries in health care facilities. https://www.jointcommission.org//media/tjc/documents/resources/patient-safety-topics/sentinelevent/sea_55_falls_4_26_16.pdf

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

26

Joint Commission. (2021, July). Sentinel events (SE). https://www.jointcommission.org//media/tjc/documents/resources/patient-safety-topics/sentinelevent/camh_24_se_all_current.pdf
Jones, K. J., Crowe, J., Allen, J. A., Skinner, A. M., High, R., Kennel, V., & Reiter-Palmon, R.
(2019). The impact of post-fall huddles on repeat fall rates and perceptions of safety
culture: A quasi-experimental evaluation of a patient safety demonstration. BMC Health
Services, 19, Article 650. https://doi.org/10.1186/s12913-019-4453-y
King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention on
nurses and care of fall risk patients. The Gerontologist, 58(2), 331-340.
https://doi.org/10.1093/geront/gnw156
Kobayashi, K., Imagama, S., Inagaki, Y., Suzuki, Y., Ando, K., Nishida, Y., & Ishiguro, N. (2017).
Incidence and characteristics of accidental falls in hospitalizations. Nagoya Journal of
Medical Science, 79(3), 291-298. https://doi.org/10.18999/nagjms.79.3.291
Korkis, L., Ternavan, K., Ladak, A., Maines, M., Ribeiro, D., & Hickey, S. (2019). Mentoring
clinical nurses toward a just culture: Successful implementation of nursing peer case
review. Journal of Nursing Administration, 49(7/8), 384-388.
https://doi.org/10.1097/NNA.0000000000000772
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: State of science.
Clinics in Geriatric Medicine, 35(2), 273-283. https://doi.org/10.1016/j.cger.2019.01.007
Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P.,
Turenen, H., & Tella, S. (2020). Action after adverse events in healthcare: An integrative
literature review. International Journal of Environmental Research and Public Health,
17(13), Article 4717. https://doi.org/10.3390/ijerph17134717

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

27

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and
healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk factors for falls in hospital inpatients: A prospective nested case control study. International Journal for Health Policy
and Management, 8(5), 300-306. https://doi.org/10.15171/IJHPM.2019.11
O’Donovan, R., Ward, M., De Brun, A., & McAuliffe, E. (2019). Safety culture in health care
teams: A narrative review of the literature. Journal of Nursing Management, 27(5), 871883. https://doi.org/10.1111/jonm.12740
O’Neil, C. A., Krauss, M. J., Bettale, J., Kessels, A., Constantinou, E., Dunagan, W. C., & Fraser,
V. J. (2018). Medications and patient characteristics associated with falling in the hospital.
Journal of Patient Safety, 14(1), 27-33. https://doi.org/10.1097/PTS.0000000000000163
Press Ganey. (2020). Guidelines for data collection and submission on patient falls indicators.
https://members.nursingquality.org/NDNQIPortal/Documents/General/Guidelines%20%20PatientFalls.pdf?linkid=s0_f776_m73_m230_a0_m236_a0_m242_a0
Roberts, S., & Cronin, S. N. (2017). A descriptive study of nursing peer-review programs in US
Magnet hospitals. Journal of Nursing Administration, 47(4), 226-231.
https://doi.org/10.1097/NNA.0000000000000469
Staggs, V. S., Turner, K., Potter, C., Cramer, E., Dunton, N., Mion, L. C., & Shorr, R. I. (2020).
Unit-level variation in bed alarm use in US hospitals. Research in Nursing and Health,
43(4), 365-372. https://doi.org/10.1002/nur.22049
Trinh, L. T. T., Assareh, H., Wood, M., Addison-Wilson, C., Sathiyaseelan, Y. (2020). Falls in
hospital causing injury. Journal for Healthcare Quality, 42(1), 1-11.
https://doi.org/10.1097/JHQ.0000000000000179

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

28

Turner, K., Staggs, V., Potter, C., Cramer, E., Shorr, R., & Mion, L. C. (2020). Fall prevention
implementation strategies in use at 60 United States hospitals: A descriptive study. BMJ
Quality and Safety, 29(12), 1000-1007. https://doi.org/10.1136/bmjqs-2019-010642
White, R. M., & Delacroix, R. (2020). Second victim phenomenon: Is ‘just culture’ a reality? An
integrative review. Applied Nursing Research, 56, Article 151319.
https:/gfct55/doi.org/10.1016/j.apnr.2020.151319

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

29
Appendix A

Evaluation and Synthesis Tables
Table A1
Evaluation Table Qualitative Studies
Citation

Theory/Co
nceptual
Framework

Design/Method/Sa
mpling

Bowen-Brady et
al., (2019). Asking
for feedback:
Clinical nurses’
perceptions of a
peer review
program in a
community
hospital.

Not stated,
inferred
phenomenol
ogy
framework

Design: Descriptive
qualitative with
focus groups and
interviews

Country: US
Funding: None
Bias: None listed

Purpose:
Understand nurses’
perceptions of an
annual peer review
process

Sample/Setting

N = 11
Demographics:
-Nurses
-25-59 years old
(72.2%)
-Caucasian (81.82%)
-Bachelor’s (81.82%)
->20 years
experience (54.55%)
Setting:
162-bed community
hospital
Exclusion:
-Employment < 6
months
-No previous
participation in
hospital’s NPR
process
Attrition: 0

Major Themes
Studied/Definitions

Research Questions:
1. What is NPR
2. How are facilitators
part of the NPR
process?
3. What are barriers to
NPR?
4. What can be learned
from NPR?
Definitions:
NPR – process by
which nurses assess,
monitor, & make
judgements about the
quality of nursing care
provided by peers

Measurement/
Instrumentati
on
Focus groups
Open-ended
questionnaires
Digital voice
recorders
Professional
transcription
service

Data
Analysis

Calaizzi’s
analysis

Findings/Themes

Themes:
1. What is NPR?
-It’s professional, not
personal
-Personal growth &
development
2. Facilitating the
NPR process
-Peer facilitators: an
essential role
-Education is key
3. Barriers to NPR
-Dedicated
time/space/privacy/le
adership support
-Clinical nurse
engagement
-Difficult
conversations
4. Lessons learned
-1st year vs. 2nd year
meaningful
experience

Level/Quality of
Evidence/Decision for
Practice/Application to
Practice
Level of Evidence: VI
Strengths: strong
qualitative design;
incorporating the
American Nurses
Associations’ (ANA) peer
review guidelines into
clinical practice
Weaknesses: small N;
conducted in small
community hospital
(limits generalizability);
low level of evidence
Application:
NPR plays an essential
role in improving that
quality & safety of
nursing care; repeated
participation enhances
nurses’ understanding of
peer review; supports use

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

King et al., (2018).
Impact of fall
prevention on
nurses and care of
fall risk patients.
Country: US
Funding:
Clinical and
Translation Science
Award program
through NIH
National Center for
Advancing
Translation
Sciences
Bias: None

Theory/Co
nceptual
Framework

Grounded
Theory

Design/Method/Sa
mpling

Design: Qualitative
with focus groups
and interviews
Purpose:
Explore nurses’
experiences with fall
prevention in
hospital settings &
the impact of these
experiences on how
nurses provide are to
fall risk patients

Sample/Setting

N = 27
Demographics:
-34.3% patient bed
days (site A) &
54.4% (site B) are
occupied by patients
65 years old and
older
Setting:
-530-bed hospital
(site A) & 81-bed
teaching hospital (site
B)
-4:1 nurse to patient
ratio
Exclusion:
-Nurses not in formal
leadership roles
-Not employed on
medical, surgical, or
medical/surgical unit
with patients 65 years
and older
Attrition: 0

30
Major Themes
Studied/Definitions

Research Questions:
1. What are inpatient
nurses’ experiences
with fall prevention?
2. How do these
experiences impact
how nurses provide
care to fall risk
patients?

Measurement/
Instrumentati
on

Focus group
1:1 interviews
Audio
recorders
Transcription

Data
Analysis

Grounded
dimensional
analysis;
open, axial
& selective
coding

Findings/Themes

Level/Quality of
Evidence/Decision for
Practice/Application to
Practice

-Modeling lifelong
learning
-A request for ongoing peer review to
hold one another
accountable
Themes:
1. Fall Message:
-“Zero falls”
message
-Identifying units as
“high-fall” or “lowfall” units
-Varying fall
message intensity
depending on how
often, who sent it,
and the tone of the
message
2. Intense
Messaging
-Fearful of falls
-Culture of blame or
shame
3. Impact on
Nursing Practice:
-Overidentification
of fall risk patients
-Restricting pts’
movement
-Overwhelmed with
fall prevention
4. Conditions to
Progress Fall Risk
Patients

of ANA Guidelines and
Contemporary Principles
of Peer Review Process

Level of Evidence: VI
Strengths: strong
qualitative design;
heterogenic setting sample
Weakness: small N;
limited to medicalsurgical units (limits
generalizability); low
level of evidence
Application: Intense fall
prevention pressure
creates negative
outcomes; leads to
restriction of patients’
movement, impeding w/
their recovery;
dependency on bed/chair
alarms, which creates
chaos; places fear of
falling in patients

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

LeLaurin &
Shorr, (2019).
Preventing falls in
hospitalized
patients: State of
the science.

Theory/Co
nceptual
Framework

Not stated,
inferred
Grounded
Theory

Country: US
Funding: None

Design/Method/Sa
mpling

Design: Metasynthesis
Purpose: To
examine fall
prevention
intervention
strategies in
hospitals

Sample/Setting

N = 58
Inclusion: Hospital
settings
Exclusion:
Outpatient or
community dwelling
settings

31
Major Themes
Studied/Definitions

Themes:
1. Single Fall
Prevention
Interventions

Measurement/
Instrumentati
on

Varied based
on study
reviewed

Data
Analysis

Not
described

2. Multifactorial
Interventions

Bias: None

Liukka et al.,
(2020). Action after
adverse events in
healthcare: An
integrative review.
Country: Finland
Funding: None

Whittemore
and Knafl’s
five stages
of
integrative
review

Design: Systematic
review
Purpose: Synthesize
knowledge, theory,
and evidence
regarding action
after AEs in

N= 25
DS: Scopus;
CINAHL; Cochrane;
PubMed

Research Question:
What are key elements
of action immediately
after AEs in healthcare
organizations?

Inclusion: published
2009-2018; English

Themes:
1. First Victim

Varied based
on study
reviewed

Inductive
content
analysis;
PRISMA

Findings/Themes

-Patient ambulation
encouraged &
rewarded
-Investigating the
environment & risk
factors surrounding
the fall, rather than
the individual nurse
themself
1. Single Fall
Prevention
Interventions
-Fall risk
identification
-Alarms
-Sitters
-Intentional rounding
-Patient education
Environmental
modifications
-Physical restraints
-Non-slip socks
2. Multifactorial
Interventions
-Limited evidence
1. First Victim
-Attention in
revealing an AE
-Communication
after AEs
-Victim support
-Complete apology
2. Second Victim

Level/Quality of
Evidence/Decision for
Practice/Application to
Practice

Level of Evidence: V
Strengths: large N
Weaknesses: few highlevel studies were
reviewed; did not outline
search strategy or data
analysis techniques
Application: Most fall
prevention literature
includes quality
improvement studies, thus
higher-level research
studies need to be
conducted
Level of Evidence: V
Strengths: strong study
design; thorough search
strategy
Weaknesses: small N;
few high-level studies

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

Bias: None

Theory/Co
nceptual
Framework

Design/Method/Sa
mpling

hospitals and
primary care units

Sample/Setting

language; reported
action after AE
Exclusion: AE
reports; not an
empirical study or
literature review

32
Major Themes
Studied/Definitions

2. Second Victim
3. Third Victim
Definitions:
1st victim – patients
and their families
2nd victim – healthcare
providers
3rd victim – healthcare
organizations

Measurement/
Instrumentati
on

Data
Analysis

Findings/Themes

-Support type
-Coping strategies
-Professional
changes after AEs
-Learning about AE
phenomenon
3. Third Victim
-Action after AE
strategy
-Action after AE
infrastructure
-Open disclosure
about AE
-Action after AE
training

Level/Quality of
Evidence/Decision for
Practice/Application to
Practice
were reviewed; omitted
national guidelines
Application: Action after
AEs should take into
account first, second, and
third victims, in order to
develop evidenced-based
processes to respond to
AEs

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

33

Table A2
Evaluation Table Quantitative Studies
Citation

Theory/Co
nceptual
Framework

Design/Method

Edwards, (2018a).
In pursuit of quality
and safety: An 8year study of
clinical peer
reviews best
practices in US
hospitals.

None stated,
inferred
Social
Cognitive
Theory

Design:
Longitudinal cohort
with surveys

Country: US
Funding: None

Purpose: Assist
healthcare leaders in
re-designing clinical
PR programs to
maximize the impact
on the quality and
safety of patient care

Sample/Setting

Major Variables &
Definitions

N = 270

IV: Clinical PR

Response Rate:
270/457 (59%)

DV1: Annual rate of
PR program change

Demographics:
Regions:
-Northeast (N=60)
-South (N=61)
-Midwest (N=95)
-West (N=54)

DV2: QI model scores

Measurement/I
nstrumentation

Online survey

Data
Analysis

Paired ttests;
Pearson
chi-square;
ordinal
logistical
regression

Findings/Results

DV1: Mean 20% [1124%)
DV2: Mean increase
5.6 [2.9-8.3]

None stated,
inferred
Social
Cognitive
Theory

Design: Mixed
methods with
surveys

Strengths: large N;
heterogenic sample;
strong data analysis

Application: There is a
large gap between
clinical PR and best
practices used to
achieve high-quality
and safe patient care,
reinforcing the need for
organizations to revisit
their current programs

Council of Teaching
Hospitals members
(N=62)

Edwards, (2018b).
An assessment of
the impact of Just
Culture on quality

Level of Evidence: IV

Weaknesses:
convenience sampling
method; data selfreported and un-audited

Staffed beds:
>500 (N=48)
200-499 (N=104)
50-199 (N=90)
<50 (N=28)

Bias: None

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice

Setting: Acute care
hospitals in US
N = 270

IV: Clinical PR

Response Rate:
270/457 (59%)

DV1: Just Culture
adoption

Online surveys
(yes/no; 6-point
Likert scale)

Pearson
chi-square;
ANOVA

DV1: N=211, 79%

Level of Evidence: IV

DV2:
-Strongly positive
(N=33, 16%)

Strengths: large N;
heterogenic sample;
strong data analysis

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

and safety in US
hospitals.
Country: US
Funding: None
Bias: None

Theory/Co
nceptual
Framework

Design/Method

Purpose: Assemble
data relevant to
hospital safety
culture and clinical
PR, to further assess
the impact of Just
Culture on quality
and safety

34

Sample/Setting

Major Variables &
Definitions

Demographics:
Regions:
-Northeast (N=60)
-South (N=61)
-Midwest (N=95)
-West (N=54)

DV2: Perceived
impact of Just Culture

Staffed beds:
>500 (N=48)
200-499 (N=104)
50-199 (N=90)
<50 (N=28)

DV4: Associations
with PR program and
Just Culture impact

Council of Teaching
Hospitals members
(N=62)
Setting: Acute care
hospitals in US

DV3: Associations
with PR program and
Just Culture adoption

Measurement/I
nstrumentation

Data
Analysis

Findings/Results

-Positive (N=77, 37%)
-Somewhat positive
(N=68, 33%)
-No apparent effect
(N=27, 13%)
-Somewhat negative
(N=2, 1%)
-Negative (N=1, 0%)
-Strongly negative
(N=1, 0%)
-No response (N=1,
0%)
DV3:
-Organizational
leadership (p=.005)
-Primary goal to
improve quality and
safety (p <.001)
-Monitoring
counts/patterns of
system or process of
care improvement
opportunities identified
(p=.005)
-Documenting cases in
which excellent
clinical performance
was recognized
(N=.001)

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice
Weaknesses: selfreported data; variation
in the interpretation of
Just Culture;
convenience sampling
Application: More
research is needed
regarding the efficacy of
Just Culture on the
quality and safety of
patient care

DV4:
-Organizational
leadership (p <.001)

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

Herrington &
Hand, (2019).
Impact of nurse
peer review on a
culture of safety.
Country: US
Funding: None
Bias: None

Theory/Co
nceptual
Framework

None stated,
inferred
Social
Cognitive
Theory

Design/Method

Design: Descriptive
with surveys
Purpose: Develop,
implement, and
evaluate an NPR
program

Sample/Setting

35
Major Variables &
Definitions

N = 26

IV: NPR program

Demographics:
Nurses with
experience:
<1 year (N=3)
1-5 years (N=6)
6-8 years (N=8)
11-15 years (N=3)
16-20 years (N=4)
>20 years (N=2)

DV1: Mistakes lead to
positive change

Setting: 355-bed
acute care hospital in
Midwestern US;
Magnet; participates
in NDQNI
Inclusion: nurses on
pediatric, neonatal
intensive care,

DV2: Staff will freely
speak up

Measurement/I
nstrumentation

Pre and post
assessments
using the
Agency for
Healthcare
Research and
Quality Hospital
Survey

Data
Analysis

Paired
sample ttests;
Cohen’s d

Findings/Results

-Likelihood of selfreporting cases for PR
(p=.003)
-Quality of case review
(p<.001)
-Level of reviewer
participation in PR
process (p<.001)
-Perceived PR impact
on quality and safety
(p<.001)
-Medical staff
perceptions of the PR
program (p<.001)
DV1: p < .001, d =
1.31
DV2: p =.002, d = 0.67

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice

Level of Evidence: VI
Strengths: heterogenic
sample; strong data
analysis
Weaknesses: small N;
low level of evidence;
focus on one
geographical area
Application: NPR is a
valuable tool for case
view that allows nurses
to speak up, receive
valuable feedback, and
create an environment
the supports a safety of
patient culture

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

Theory/Co
nceptual
Framework

Design/Method

Sample/Setting

36
Major Variables &
Definitions

Measurement/I
nstrumentation

Data
Analysis

Findings/Results

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice

postpartum, or labor
and delivery units
Korkis et al.,
(2019). Mentoring
clinical nurses
toward a just
culture.

None stated,
inferred
Social
Cognitive
Theory

Country: US
Funding: None
Bias: None

Design: Descriptivemixed methods with
questionnaires
Purpose: To
analyze an NPR that
supports QI and Just
Culture principles
through assigned
time for facilitated,
peer-to-peer,
nonpunitive
dialogue that focuses
on clinician
performance and
systems
improvement

Attrition: 0
N= 13
Demographics:
Nurses represented
from each specialty
area
Case type:
Anesthesia; blood
transfusion;
diagnoses/treatments/
orders; falls;
tubes/intravenous
lines/drains; delay in
treatment; medication
issues

IV: NPR program
DV1: Understanding
of NPR
DV2: Comfort with
NPR
DV3: Comfort to
initiate safety
conversations

Pre and post
questionnaires
(1 open-ended
narrative & 3
closed-ended
items using 5point Likert
scale)

Descriptive
statistics

DV1: ΔI: 1.44

Level of Evidence: VI

DV2: ΔI: 1.31

Strengths: measured
quantifiable outcomes;
assessed a variety of
case types

DV3: ΔI: 0.46
Themes:
-Learning experience
-NPR council was
thoughtful & courteous
-Nonpunitive
-Improved nurses’
autonomy &
accountability

Research Question:
What are your top-2
take away points from
participating in NPR?

Setting: 265-bed
acute care hospital on
Pacific coast;
unionized; Magnet;
employs 1,000 nurses

Weaknesses: small N;
low level of evidence;
focus on one
geographical area
Application:
Implementing a
mentorship-based NPR
program encourages
nurse participation and
advances Just Culture
principles

Attrition: 0
Roberts & Cronin,
(2017). A
descriptive study of
nursing peer-review

Not stated,
inferred
Grounded
Theory

Design: Descriptive
with surveys
Purpose: Assess
the types of NPR

N = 41

IV: NPR program

Demographics:
Bed-size: 75 patients>500 patients

DV1: NPR program
description

Telephone or
online surveys

Descriptive
statistics

DV1:
- Case review/root
cause analysis structure
(N=30, 73%)

Level of Evidence: VI
Strengths: heterogenic
sample - variable
hospital locations, sizes

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

programs in US
Magnet hospitals.
Country: US
Funding: None
Bias: None

Theory/Co
nceptual
Framework

Design/Method

programs in US
Magnet hospitals

Sample/Setting

Hospital type:
General acute care;
specialty;
government;
teaching/academic
medical center
Setting: Magnet
hospitals representing
9 geographical
regions throughout
the US
Attrition: 0

37
Major Variables &
Definitions

DV2: NPR outcome
measurement
DV3: NPR barriers

Measurement/I
nstrumentation

Data
Analysis

Findings/Results

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice

-Preemptive
investigation (N=1,
2%)
-Other (N=10, 25%)

& types (increases
generalizability; first
known study to evaluate
current NPR program in
place

DV2:
-No. of cases (N=6,
15%)
-No. of systematic
changes (N=14; 34%)
-No. of improvements
(N=2, 5%)
-Improvement in
specific outcome (N=5,
12%)
-Improvement in nurse
satisfaction (N=1, 2%)
-Other (N=9, 22%)
-None (N=15, 37%)
DV3:
-Nurses unable to
distinguish or lack of
agreement on practice
variations (N=7, 17%)
-Coworkers view
conversations at
criticism (N=13, 32%)
-Uncomfortable
approaching peers or
fear retribution (N=10,
25%)
-Worry labeled as
troublemaker (N=2,
5%)

Weaknesses: small N;
low level of evidence;
survey allowed for
answers to be given
with varying
descriptions – some
answers were short &
some were more
descriptive
Application: There is
wide variability of NPR
programs in the US and
many are not supported
by data, more research
is needed to measure the
outcomes of NPR
programs

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

Turner et al.,
(2020). Fall
prevention
implementation
strategies in use at
60 United States
hospitals: A
descriptive study.
Country: US
Funding: National
Institute on Aging
Bias: None

Theory/Co
nceptual
Framework

Not stated,
inferred
Grounded
Theory

Design/Method

Design: Descriptive
cross-sectional with
surveys
Purpose: Identify
and describe the
prevalence of
specific hospital fall
prevention
implementation
strategies

Sample/Setting

N = 60
Response Rate:
60/80 (75%)
Demographics:
Hospital ownership:
-Not-for-profit
(N=59, 98%)
-For profit (N=1, 2%)
Bed size:
<200 beds (N=32,
53%)
>200 beds (N=28,
47%)
-Urban (N=54, 90%)
-Magnet (N=32,
53%)

38
Major Variables &
Definitions

Measurement/I
nstrumentation

IV: Fall prevention
strategies

Online Press
Ganey survey

DV1: Leadership
support

NDNQI site
coordinator

DV2: Education for
staff, patients, and
families

Data
Analysis

Descriptive
statistics;
complete
case
analysis;
Reporting
of
Observatio
nal Studies
in
Epidemiolo
gy
checklist

Findings/Results

-Lack of support or
change in practice
(N=4, 10%)
-Nurses feel that the
primary nurse is in
charge (N=0, 0%)
-Time to do peer
review (N=9, 22%)
-Lack of cases for
review or participation
(N=5, 12%)
-Other (N=3, 7%)
-None (N=11, 27%)
DV1 (N=60):
1. Setting expectations:
-Used at least 1 setting
expectations strategy
(N=60, 100%)
-Falls policies have
been updated in last 3
years (N=59, 98%)
-Falls included in
annual board of
trustees’ report (N=57,
95%)
-Falls reviewed
quarterly by top
leadership (N=56,
93%)
-Safety officer or
director (N=39, 65%)
-Unit manager (N=24,
40%)

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice

Level of Evidence: VI
Strengths: heterogenic
hospital size; first
known study to examine
which hospital fall
prevention strategies are
being used and how
they are implemented
Weaknesses: small N;
low level of evidence;
urban locations
overrepresented;
hospitals self-selected to
participate
Application: Further
research is needed to
examine fall prevention
strategies and which are
most effective in

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

Theory/Co
nceptual
Framework

Design/Method

Sample/Setting

Setting: US hospitals
participating in
NDQNI

39
Major Variables &
Definitions

Measurement/I
nstrumentation

Data
Analysis

Findings/Results

2. Providing rewards
(for-high performing
units)
3. Providing support:
-Used at least 1 support
strategy for low
performing units
(N=37, 62%)
-Quality
management/safety
consultation (N=30,
50%)
-Interdisciplinary
consultation (N=13,
22%)
-Additional equipment
or furniture (N=10,
17%)
-Additional staffing
(N=6, 10%)
-Chair alarms (N=58,
97%)
-Bed alarms (N=54,
90%)
-Sitters (N=53, 88%)
-Low beds (N=37,
62%)
-Safety equipment
(N=27, 45%)

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice
reducing falls, guiding
future fall prevention
intervention
development

DV2 (N=58):
1. Education at staff
orientation:
-Overall (N=58, 100%)

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Citation

Theory/Co
nceptual
Framework

Design/Method

Sample/Setting

40
Major Variables &
Definitions

Measurement/I
nstrumentation

Data
Analysis

Findings/Results

Level/Quality of
Evidence/Decision for
Practice/Application
to Practice

-Nursing staff only
(N=45, 78%)
-All employees (N=13,
22%)
2. Annual staff
training:
-Overall (N=40, 69%)
-Nursing staff only
(N=24, 41%)
-All employees (N=16,
28%)
3. Patient/families:
-1-on-1 education
(N=57, 98%)
-Printed materials
(N=49, 85%)
-Fall prevention video
on TV (N=16, 28%)

Key: AE – adverse event; ANOVA – analysis of variance; DS – databases searched; DV – dependent variable; EHR – electronic health record; IQR
– interquartile range; IV – independent variable; M – median; N – number of participants; NDQNI – National Database of Nursing Quality
Indicators; No. – number; NPR – nursing peer review; PR – peer review; PRISMA – Preferred Reporting Items for Systematic Reviews and MetaAnalyses; QI – quality improvement; d – Cohen’s d; p – p value; ΔI – pretest to posttest change

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

41

Table A3
Synthesis Table
Author/Year
Design/LOE
Sample
Country
N
Setting
Bed size

>500
200-499
<200

Inpatient
Magnet
Interventions
AER
FP
NPR
PR
Outcomes
FP education
Just Culture
Leadership
support

BowenBrady et
al., 2019

King et
al.,
2018

LeLaurin &
Shorr, 2019

Liukka et
al., 2020

Edwards,
2018a

Edwards,
2018b

Herrington &
Hand, 2019

Korkis et
al., 2019

QS, VI

MS, V

MS, V

LC, IV

MM, IV

DS, VI

DMM,
VI

US
11

US
27

US
58

Finland
25

US
270

US
270

US
26

US
13

X
X
X
X

X

X

X

X
X
X
X

X
X

X

QS, VI

X
X
X

X
X

X

Roberts &
Cronin,
2017

Turner et
al., 2020

DS, VI

DCS, VI

US
41

US
60

X
X

X
X
X
X
X

X
X
X
X

X

X

X
X

X

X

X
X

X







Key: AER – adverse-event review; DCS – descriptive cross-sectional; DMM – descriptive mixed methods; DS – descriptive study; FP – fall
prevention; LC – longitudinal cohort; MM – mixed-methods; MS – meta-synthesis; N – sample size; NPR – nursing peer review; PR – peer review;
QI – quality improvement; QS – qualitative study

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Nurse autonomy
& accountability
Nurse satisfaction
NPR
understanding
QI score
Themes
FP
Interventions
Fall message
Nurse impact
Victims
NPR
Barriers
Definition
Facilitation
Lessons

42













X
X
X
X
X
X
X
X

X
X

Key: AER – adverse-event review; DCS – descriptive cross-sectional; DMM – descriptive mixed methods; DS – descriptive study; FP – fall
prevention; LC – longitudinal cohort; MM – mixed-methods; MS – meta-synthesis; N – sample size; NPR – nursing peer review; PR – peer review;
QI – quality improvement; QS – qualitative study

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Appendix B
Project Approvals

43

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

44

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Appendix C
Instruments
Figure C1
Hospital Survey on Patient Safety

45

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

46

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE

47

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Figure C2
Post-Fall Nursing Peer Review Survey

48

NURSING PEER REVIEWS TO IMPROVE SAFETY CULTURE
Appendix D
Budget

49