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

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Title: MASSACHUSETTS BOARD OF REGISTRATION IN NURSING A Study of Selected Complaint Cases to Identify Evidence-based Strategies to Prevent the Occurrence of Nursing Errors Carol Silveira April 2008 TERCAP Forum


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
    Boards 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

LPNs RNs Total LPNs RNs CY 05 closed complaint cases
44 34 78 12
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/intenti
    onal 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
Nursing Error LPN (n 44) RN (n 34) Total (N 78)
Medication 23 19 42
Lack of clinical judgment 11 6 17
Lack of professional responsibility/patient advocacy 3 3 6
17
RESULTS Nursing Error Profile
  • Most common time of day
  • 500 p.m. to 630 p.m.
  • 500 a.m. to 630 a.m.
  • Most common month
  • October
  • May
  • December

18
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19
Medication Errors
  • Possible contributing factors Individual
  • Violation of the 5 Rs and 3 vs
  • 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
Probation response Suspension response Revocation response
RNs and LPNs (N 1099) 60 38 23
23
Comparison of ISMP Findings and Actual BON Actions
Probation Suspension Revocation
ISMP respondent perceived action (N 1099) 60 38 23
actual CY 05 BON actions in response to all med errors (N 56) 5 2 0
24
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25
Clinical Judgment Errors
  • Possible contributing factors Individual
  • Deficits in knowledge, skills, abilities
  • Failure to recognize implications of S/S or
    nurses 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
  • Teams 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 3vs
  • 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/surve
    illance, 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
Age Number Percent
25-34 9 14.52
35-44 12 19.35
45-54 24 38.71
55-64 15 24.19
Over 65 1 1.61
47
Results Years Licensed
Years Number Percent
lt 5 11 17.7
5-10 13 21.0
11-15 11 17.7
16-20 9 14.6
21-25 5 8.1
gt25 9 14.5
48
Results Highest Degree
Degree Number Number Percent
Diploma Diploma 7 11.30
Associates Associates 27 43.50
Baccalaureate Baccalaureate 19 30.61
Masters Masters 8 12.09
49
Results Place of Employment
Setting Number Number Percent
Hospitals Hospitals 43 69.4
Offices/Clinics Offices/Clinics 5 8.0
Home Care Home Care 6 9.7
LTC LTC 5 8.1
Other Other 3 4.8
50
Results Position
Number Number Percent
Direct Care Direct Care 38 61.3
Charge Charge 6 9.7
N. Manager N. Manager 4 6.5
Combination D. C. / Manager Combination D. C. / Manager 12 19.4
51
Results - Employment Outcome
Number Percent
Dismissed/Resign 39 62.9
Resigned 6 9.7
Stayed with Emp. 16 25.8
52
Results - Demographics
  • 45-54 years old
  • Licensed for 5-15 years
  • Direct care provider in a hospital setting
  • ADN educated
  • Worked 5 or less years with employer
  • Either dismissed or asked to resign their
    employment

53
Results Research Question 2
  • What are the incidences of threats?
  • Individual
  • Healthcare Team
  • Patient
  • System
  • Types of errors?

54
Results Individual Factors
Thirty six (69) selected at least one
Number Percent
Fatigue 14 27
Inexperience 11 21
Mental Health 4 8
Drug/ SA 3 6
Other 14 27
55
Results Healthcare Team Factors
  • Forty two (81) selected at least one

Number Percent
Communication 28 54
Lack of teamwork 23 44
Inadequate pt. support 9 17
Unwritten unit customs 17 33
56
Results Patient Factors
  • Thirty nine (75) selected at least one

Number Percent
Altered Consciousness 13 25
Cognitive Impairment 10 19
Communication Difficulty 9 17
Other 14 27
57
Results System Factors
  • Forty six (88) selected at least one

Number Percent
Communication 11 21
Environmental 14 27
Staffing 31 60
Management factors 23 44
Back up and support 15 29
58
Results Other System/Team
  • Forty eight (92) selected at least one

Number Percent
Lack of team support 30 58
High work volume 29 56
No breaks 7 13
Lack of orientation/training 10 19
Conflict with the team 15 29
Overwhelming assignments 21 40
59
Results Types of Errors
Number Percent
Documentation 28 54
Medication Administration 23 44
Intervention 19 36
Interpretation 18 35
Attentiveness / Surveillance 16 31
Clinical Evaluation 16 31
Patient Advocacy 14 27
Prevention 11 21
Number responding that an error type
contributed to the event either moderately or
greatly
60
Results -- Research Question 3
  • What are the incidences of the level of harm to
    the patient?

61
Results Level of Harm
   Number Percent 
No Harm 33 63
Harm 5 10
Significant Harm 6 12
Death 7 13
62
Results Level of Harm
  • When a patient suffered significant harm or
    death, the respondents reported the following
    types of errors

Patient Death (N7) Sig.Harm (N6)
Intervention 6 4
Clinical Evaluation 3 6
Documentation 4 4
Attentiveness / Surveillance 3 5
Interpretation 3 1
Patient Advocacy 2 3
Medication Administration 1 3
Prevention 1 2
63
Results Research Question 4
  • What changes in practice do RNs sanctioned by
    the BON describe after the error event and what
    suggestions do they have for other nurses?

64
Results
  • Two Open Ended Questions
  • Did this event change your practice and, if so,
    how?
  • Based on what you have learned, what suggestions
    would you pass on to help other nurses prevent
    error events?

65
Results Changes in Practice
Responses from 55 participants were developed
into themes
System 0
Team members 6
Health care team factors 12
Individual factors 40
Patient factors 1
Specific types of errors 11
Did not change practice 4
No longer work in nursing 11
66
Results Suggestions to others
Responses from 53 participants were developed
into themes
System 10
Team members 10
Health care team factors 21
Individual factors 31
Patient factors 1
Specific types of errors 12
67
Results New Themes
  • Use of the word trust
  • Increased/decreased self confidence

68
Conclusions Incidences of threats and types of
errors
  • Comprehensive identification of factors
  • Open ended questions facilitated identification
    of individual factors
  • Documentation issues important

69
Recommendations
  • Nursing Theory
  • Nursing Policy
  • Nursing Practice
  • Nursing Research

70
Recommendations
  • Nursing Theory
  • Simplicity of TEMM constructs provided a valuable
    heuristic approach to investing the variables of
    interest
  • Concepts in TERCAP instrument provided an
    effective method for data analysis
  • Importance of language in the development of
    instruments
  • Error management strategies should be
    investigated

71
Recommendations
  • Nursing Policy
  • BONs are developing new methodologies for
    investigating nursing error
  • Strategies based on input from the nurse may
    helpful for remediation
  • Nurses should know nursing laws and regulations

72
Recommendations
  • Nursing Practice
  • All factors should be reviewed in pertinent error
    events
  • Staffing and high work load issues must be
    addressed
  • Nursing educators and practicing nurses should
    understand human factors and the
    multi-dimensional aspects of error
  • Methodologies should be implemented so nurses can
    recognize and address systems factors
  • Nurses should know and comply with appropriate
    the laws and regulations primarily duty to the
    patient
  • Nurses should learn to trust themselves to do the
    right thing and not do something they are not
    confident in doing

73
Recommendations
  • Nursing Research
  • All nurses are aging, are there implications for
    patient safety?
  • Are ADNs over-represented in the population of
    disciplined nurses? If so, why?
  • This study found a significant correlation
    between errors related to a breakdown in Clinical
    Evaluation and Attentiveness/Surveillance and the
    level of patient harm. Further research is
    needed to better understand these relationships.
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