FY 2005 Legislative Directive

1. MASSACHUSETTS BOARD OF REGISTRATION IN NURSINGA Study of Selected Complaint Cases to Identify Evidence-based Strategies to Prevent the Occurrence of Nursing Errors Carol Silveira April 2008 TERCAP Forum

2. FY 2005 Legislative Directive • Compile complaint cases involving preventable medical error → harm • Nurse, hospitals and pharmacies to modify practices • Report findings to DPH Commissioner, House and Senate Ways and Means, and Health Care Committees

3. Study Objectives • Describe characteristics of the nurse, patient, setting • Categorize errors and harm outcome • Examine cause or contributing factors • Identify BRN and employer actions • Recommend error-prevention strategies

4. Study Methodology • 661 complaint cases closed in CY 2005 • Case study format • Sample: Three-tiered selection process • Tier 1: Allegation code • Tier 2: Board action • Tier 3: Nursing error

5. Study Methodology Types of complaint cases considered • Improper controlled substances documentation • Medication errors • Patient neglect • Standard of practice violation • Unprofessional conduct • Dismiss - discipline not warranted → suspension

6. Study Methodology Types of complaint cases NOT considered • Drug diversion or abuse • Discipline by another BON • Patient abuse • Dismiss - lack of evidence or licensee entered Board’s SARP

7. Study Methodology Nursing error defined as… Failure of a planned nursing action to be completed as intended or the use of a wrong nursing plan to achieve an aim (adapted 1999 IOM “error” definition)

8. Study Methodology Sample

9. Study Methodology • Data collection instrument = TERCAP • Major TERCAP modifications • MA BORP Categories of Events in lieu of Patient Harm Index • No “Continued Competence” and “Misconduct/intentional Behaviors”

10. Study Limitations • Limited ability to generalize • Case file not designed for RCA • Limited consumer-reported errors

11. RESULTS: Nurse Profile(N = 78) • Gender: Female • Average age: 44 years (range: 24 to 69 years) • Length of licensure • RNs: avg. 15 years (range: 18 mo – 48 y) • LPNs: avg. 11 years (range: 1 mo – 44 y)

12. RESULTS: Nurse Profile(N = 78) • Nursing education • US educated • Highest RN entry-level education: AD • Job tenure and role • Average 3.6 years (range: 1 wk – 24 years) • Direct care • 21/78 (27%) worked in temporary capacity

13. Factors Associated with Nursing Error: Nurses’ Perception • Stress/high work volume • Clinical inexperience • Unfamiliar practice setting • Poor judgment

14. RESULTS: Patient Profile(N = 62) • Gender: Female • Average age: 79 years (range: 45 -96 y) • Most common diagnoses • Dementia • Diabetes • Insufficient information: Functional abilities and Language

15. RESULTS: Setting Profile(N = 50) • Location: urban and rural statewide • Avg. bed size: 131 beds (range: 63 – 333 beds) • No specific information r/t medical record type

16. Top 3 Nursing Errors

17. RESULTS: Nursing Error Profile • Most common time of day • 5:00 p.m. to 6:30 p.m. • 5:00 a.m. to 6:30 a.m. • Most common month • October • May • December

19. Medication Errors Possible contributing factors: Individual • Violation of the “5 Rs and 3 √s” • Incorrect transcription • Failure to verify drug allergy • Knowledge deficit

20. Medication Errors Possible contributing factors: System • Lack of patient identification • Novice nurse orientation/preceptorship • Amoxicillin as emergency stock drug

21. Medication Errors Possible contributing factors: System • Other • Sound alike drug name • Illegible physician writing • Increased noise • Incorrect performance of narcotic count • Lack of available drug reference • Drug label confusion • Defective dropper

22. February 2005 ISMP Survey: Nurses Perceptions of BON Actions in Response to Medication Error

23. Comparison of ISMP Findings and Actual BON Actions

25. Clinical Judgment Errors Possible contributing factors: Individual • Deficits in knowledge, skills, abilities • Failure to recognize implications of S/S or nurse’s interventions • Failure to notify MD of change in condition • Ineffective monitoring of clinical status • Knowledge deficits: Professional standards • Heat treatment applications • Resuscitation directives • Hand-off communications

26. Clinical Judgment Errors Possible contributing factors: System • Team’s lack of awareness of patient goals • Information missing from patient record • Unit-level communication breakdown • Lack of, or poor, supervisory support

27. Patient Safety Implications Orientation and Novice Nurse Transition • LTC common practice setting among novice LPNs • Adequate length and supervision • Consistency in preceptor assignment and training • Collaborative team and off-shift support

28. Patient Safety Implications Medication Administration • Error potential inherent in process • Financial and human cost • Cognitive process • Consistency in 5Rs and 3√s • System prompts

29. Patient Safety Implications Clinical Judgment • “Off-shift” expertise to support clinical decision making • Standardization of hand-off communication • Learning environment • Patient safety alerts

30. Error Prevention Strategies

31. Error Prevention Strategies • Individual nurse • Nursing education • Systems

32. CONCLUSIONS Nurse-perceived factors impacting ability to practice competently: • Stress/high work volume • Clinical inexperience • Unfamiliar practice setting

33. CONCLUSIONS • Other human factors impacting ability to practice competently • Clinical data recognition and synthesis • Adherence to nursing SOPs • Medication administration • Heat treatment • Resuscitation directives • Hand-off communications

34. CONCLUSION Practice environment (system) factors impacting ability to practice competently: • Policies • Equipment • Workflow design • Support for novice nurses and nurses assigned by temporary staff agencies • Communication

35. CONCLUSIONS • BON actions in response to nursing errors are punitive… Perception ≠ reality

36. Perceptions of Registered Nurses Sanctioned by a Board of Nursing: Individual, Health Care Team, Patient, and System Contributions to Error Mary Beth Thomas RN, PhD

37. Background • Errors in health care are one of the leading causes of patient death • National and state initiatives have been developed to address this issue • Consumer concern is evident and clear • Impact on health care providers • New knowledge for licensing boards

38. Conceptual FrameworkThreat and Error Management Model • Developed by Robert Helmreich • Created and researched within the context of the aviation industry • Recognized by the IOM for applicability to health care and is currently being tested

39. Conceptual FrameworkThreat and Error Management Model

40. Methodology Research Design • Exploratory study using a descriptive survey research design • Variables in the study include the following: • Threats – Individual, health care team, patient, and system factors • Errors – A breakdown in medication administration, documentation, attentiveness/surveillance, clinical evaluation, prevention, intervention, interpretation of doctors’ orders, and patient advocacy • Patient Outcomes – Level of harm

41. Methodology Population • RNs in Texas • Disciplinary order between December 2004 – December 2006 because of a nursing practice error • N = 613 Sample • 62 RNs completed and returned the survey

42. Methodology Instrument TERCAP (Taxonomy of Root Cause Analysis of Practice Breakdown – Responsibility) Modified TERCAP

43. Methodology TERCAP Revisions • Length • Language • Inter-rater reliability • IRB approval

44. Methodology Statistical Analysis • Frequency distributions • Percentages • Thematic Development

45. Results – Research Question 1 What is the demographic profile of RNs sanctioned by the Texas Board of Nursing (BON)?

46. Results - Age

47. Results – Years Licensed

48. Results – Highest Degree

49. Results – Place of Employment

50. Results – Position