NCSBN Practice Breakdown Study

1. NCSBN Practice Breakdown Study Kathy Apple, MS, RN Executive Director National Council of State Boards of Nursing

2. Background • Precursor Study – 1996 Study of the Effectiveness of Nursing Discipline. • Reviewed public documents of 400 cases. • Limited by wide valuation of detail in various Boards’ public document • Patient Safety Movement: Systems vs Individual Accountability

3. Pilot Study • 1999 – 2001 developed TERCAP Instrument. • Reviewed redacted files of 26 discipline cases involving practice breakdown. • Developed TERCAP. • 2002 – Refined TERCAP. • 2002-2003 – Tested Instrument 106 cases from 14 participating Boards.

4. Case Description Patient Profile Nurse Profile Education Licensure Practice History Continued Competence Nurse Narrative Setting Practice Breakdown Categories Healthcare Team Other Systems Issues Outcomes Patient Nurse Taxonomy of Error, Root Cause Analysis and Practice Responsibility (TERCAP)

5. Practice Breakdown Categories • Lack of Attentiveness/Surveillance • Lack of or Faulty Intervention • Lack of Agency/Fiduciary Concern • Inappropriate Judgment • Missed or Mistaken Order • Lack of Prevention • Documentation Errors • Medication Errors

6. All types of settings Errors that reached patient but did not cause permanent harm Timing of practice breakdown During 8-hour shift Occurred between 3 am and 9 am Occurred during first 20% shift. Nurse Profile Nurse 34-40 years of age Licensed 10-15 years Working in current position less than one year No previous job terminations Preliminary Analysis: First 106 Cases

7. Next Steps • Finalize revised instrument. • Collect and Analyze 106 cases using revised instrument. • Quantitative analysis of Nurse Narratives section of first 106 cases. • Boards will use TERCAP to record discipline cases involving practice breakdown.

8. Implications of Nursing Regulation • Identify risk factors for practice breakdown. • Collaborate with educators to identify areas for improving education. • Collaborate with nursing service to identify high risk situations and develop safeguards. New regulatory role: facilitate proactive regulation before harm occurs rather than waiting for problems to be reported.