Raising the Right Cases: Smart Escalation in Trauma Peer Review
Trauma care is fast, unforgiving, and occasionally humbling. Even in the best trauma centers, not every case ends with a textbook outcome—and not every deviation from the plan is a failure. The challenge for trauma programs is knowing when a case represents natural clinical complexity and when it signals an opportunity for improvement that warrants escalation to peer review.
Peer review is not a courtroom, a blame factory, or a professional scarlet letter. At its best, it is a structured, protected mechanism to improve systems, support clinicians, and reduce preventable harm—principles that have anchored patient safety since To Err Is Human reframed errors as system failures rather than individual shortcomings (Institute of Medicine [IOM], 2000).
So when should a trauma case move beyond primary review and into formal peer review? Let’s break it down—without breaking anyone’s spirit.
The Purpose of Escalation: Improvement, Not Indictment
Trauma peer review exists to answer one core question:
Did the care delivered align with expected standards, and if not, why?
The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) emphasizes that effective performance improvement requires structured case identification, multidisciplinary review, and documented loop closure (ACS, n.d.). Escalation is not about volume—it is about signal.
If everything goes to peer review, nothing is learned. If nothing goes, risk quietly accumulates.
Clinical Triggers That Should Prompt Escalation
While every trauma program defines its own audit filters, several clinical patterns consistently warrant peer review consideration.
1. Unanticipated Mortality or Major Morbidity
Deaths or life-altering complications that occur outside expected injury patterns or risk profiles should almost always be escalated. This includes:
Delays in hemorrhage control
Missed injuries contributing to deterioration
Failure to rescue after a recognized complication
These cases align with national patient safety principles emphasizing review of preventable harm rather than unavoidable outcomes (Bates & Singh, 2018).
2. Delays in Time-Sensitive Trauma Interventions
Trauma is a race against physiology. Peer review should be considered when there are:
Delays to trauma team activation
Delayed operative intervention
Prolonged time to blood product administration or imaging without clinical justification
TQIP benchmarking data exist precisely to help trauma programs identify whether these delays are outliers or patterns (ACS, n.d.).
3. Deviations From Evidence-Based Guidelines
Not all deviations are wrong—but all should be explainable.
Escalate when:
Established protocols (e.g., massive transfusion, TBI management) are not followed without clear rationale
Practice variation results in patient harm or near-miss events
Peer review provides the protected forum necessary to distinguish thoughtful clinical judgment from unrecognized drift in practice (Froedtert & Medical College of Wisconsin, 2024).
Behavioral and Professional Practice Indicators
Peer review is not limited to technical skill. The Joint Commission’s Ongoing Professional Practice Evaluation (OPPE) framework underscores that communication, documentation, and professionalism directly impact patient safety (Smalley et al., 2021).
Escalation may be appropriate when cases involve:
Incomplete or contradictory documentation
Breakdowns in handoff communication
Recurrent concerns tied to a single provider across multiple cases
When trends emerge, escalation supports early intervention, not punitive action (The Joint Commission, 2026).
System Failures Deserve Just as Much Attention
Sometimes the issue isn’t who delivered the care—it’s how the system set them up.
Peer review should capture:
Equipment unavailability
Staffing or coverage gaps
Workflow barriers contributing to delay or error
This systems-based approach aligns directly with the patient safety movement’s emphasis on learning organizations rather than individual fault-finding (IOM, 2000).
Repeat Signals: When One Case Becomes a Pattern
One unusual case may be noise.
Three similar cases? That’s a message.
Escalation is particularly critical when:
The same issue appears across multiple patients
Similar corrective actions fail to resolve the problem
Data trends contradict expected benchmarks
Effective trauma programs use peer review not only to close loops—but to verify that those loops stay closed (ACS, n.d.).
How Peer Review Adds Value (When Done Well)
Well-run peer review:
Protects confidentiality and psychological safety
Separates system issues from individual performance
Produces actionable, measurable improvements
Supports credentialing and professional development processes
Poorly run peer review, on the other hand, becomes theater. The difference lies in clear escalation criteria, consistent application, and documented outcomes (Froedtert & Medical College of Wisconsin, 2024).
A Practical Rule of Thumb
If you’re asking any of the following questions, the case likely belongs in peer review:
Could this happen again?
Was the standard of care unclear—or not met?
Does this reveal a system vulnerability?
Would we explain this care confidently to an external reviewer?
If the answer is “maybe,” escalate. Peer review exists precisely for that uncertainty.
Call to Action: Make Escalation Routine, Not Reactive
Trauma programs thrive when escalation is predictable, fair, and data-informed—not emotional or episodic. Now is the time to:
Revisit your trauma PIPS escalation criteria
Align audit filters with current ACS and Joint Commission expectations
Ensure peer review outcomes translate into real system change
Peer review isn’t about pointing fingers. It’s about strengthening the hands that catch the next patient.
Because in trauma care, the only true failure is failing to learn.
References
American College of Surgeons. (n.d.). Trauma Quality Improvement Program (TQIP). https://www.facs.org/quality-programs/trauma/quality/trauma-quality-improvement-program/
Bates, D. W., & Singh, H. (2018). Two decades since To Err Is Human: An assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736–1743. https://doi.org/10.1377/hlthaff.2018.0738
Froedtert & Medical College of Wisconsin. (2024). Trauma performance improvement and patient safety guideline. https://www.froedtert.com/sites/default/files/upload/docs/services/trauma/guidelines/trauma-performance-improvement-patient-safety-guideline.pdf
Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press. https://doi.org/10.17226/9728
Smalley, C. M., Baskin, B. E., Simon, E. L., Meldon, S. W., & Fertel, B. S. (2021). Ongoing professional practice evaluation for emergency medicine physicians in a large health care system. Joint Commission Journal on Quality and Patient Safety, 47(5), 318–326. https://doi.org/10.1016/j.jcjq.2020.11.002
The Joint Commission. (2026). Ongoing professional practice evaluation (OPPE): Understanding the requirements. https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000001500
