Case Review

Introduction to the Case Review Process


The goals of our Division's case review process are to: (1) improve the quality and safety of our patient care by learning from past performance, adverse events, errors, and near misses, (2) identify and suggest practice and systems improvements to prevent similar future episodes, and (3) educate all internal medicine intern physicians via an experiential opportunity of reviewing a real-life Moffitt case with a faculty-supervised, structured root cause analysis, thereby  enhancing our culture of safety within our residency program, department, and institution.

The Committee

Our Division of Hospital Medicine's Case Review Committee is composed of various leaders in hospital medicine, including faculty, fellows, and chief residents representing expertise in patient safety, quality improvement, healthcare value, medical education, clinical informatics, and multidisciplinary collaboration. In addition, all internal medicine intern physicians participate in one of our monthly meetings during their mandatory Quality Improvement rotation. Committee members act as liaisons to other parts of the hospital environment for information-gathering, cross-disciplinary dialogue, and facilitating improvements in our systems of care.

The Cases

The majority of our referrals are notably from resident and faculty physicians, which suggests a robust culture of safety and that our front-line clinicians are highly engaged in ensuring the highest standards of clinical care. Cases are also referred from incident reports, other department, other hospital committees, and patient/family grievances.

Case Actions

Cases result in many different types of actions with the overarching goal of improving our practice and systems of care. These actions include, but are not limited to: protocol development and/or revisions, information technology solutions, modifications to the electronic health record, creation of dedicated task forces/working groups, interservice meetings to resolving outstanding problems, guideline dissemination, and/or trainee and faculty conferences. Importantly, all case referrals are provided timely feedback of our committee's findings and an opportunity to request additional discussion and resources via the UCSF Patient Safety Committee's Caring for the Caregiver peer support program.


The case review process is confidential under the umbrella of quality review, which allows for open discussion of events and care improvement in an environment that is protected from medicolegal proceedings.

On-Line Tool to Refer Cases