Lourdes Moore

Date of Award


Document Type

Doctor of Nursing Practice (DNP)

Degree Name

Doctor of Nursing Practice (DNP)



Committee Chair

Kristen Herrin

Committee Member

Phyllis J. Waters


Nursing--Law and legislation, Nursing errors, Peer review


Nurses are accountable for their practice based on professional standards and the Nurse Practice Act. When patient care falls outside professional standards, the incident is considered a practice breakdown, which triggers evaluation of the nurse’s practice. Practice breakdowns are referred to a peer review committee to determine if the nurse’s actions contributed to the error and to take action to improve practice and maintain patient safety. The Nursing Department implemented the Just Culture Model into its peer review committee process by adapting an evidence-based practice investigation tool that identifies a nurse’s practice accountability. Group decision making (i.e., peer review committee) may lead to variances in decisions due to members being influenced by others’ assumptions and psychological biases (Mannion & Thompson, 2014). The structured tool provides a consistent framework for the peer review committee in deciding remediation actions relative to practice breakdowns. The purpose of the study was to determine if the nursing peer review committee’s decisions regarding nursing practice breakdowns were congruent with principles of Just Culture. Using a comparative analysis methodology, peer review committee’s decisions pre-/post-implementation of Just Culture were compared using a structured tool and Just Culture algorithm. The findings showed the introduction of structural elements that helped interpret the Nurse Practice Act and guide decision making impacted the organization’s peer review process and minimized group bias, but also diminished the ability to discern Just Culture’s influences on decisions.



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