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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.

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Presentation on theme: "MASSACHUSETTS BOARD OF REGISTRATION IN NURSING A Study of Selected Complaint Cases to Identify Evidence-based Strategies to Prevent the Occurrence of."— Presentation transcript:

1 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 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 Drug diversion or abuse Discipline by another BON
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 % CY 05 closed complaint cases
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/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: 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
Medication 23 19 42 Lack of clinical judgment 11 6 17 Lack of professional responsibility/patient advocacy 3

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

18

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
Probation % response Suspension Revocation 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

24

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 Policies Equipment Workflow design
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 Framework Threat 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 Framework Threat 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 Sample 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
Number Percent < 5 11 17.7% 5-10 13 21.0% 11-15 16-20 9 14.6% 21-25 5 8.1% >25 14.5%

48 Results – Highest Degree
Number Percent Diploma 7 11.30% Associates 27 43.50% Baccalaureate 19 30.61% Masters 8 12.09%

49 Results – Place of Employment
Setting Number Percent Hospitals 43 69.4% Offices/Clinics 5 8.0% Home Care 6 9.7% LTC 8.1% Other 3 4.8%

50 Results – Position Number Percent Direct Care 38 61.3% Charge 6 9.7%
N. Manager 4 6.5% 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

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 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%
 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 (N=7) Sig.Harm (N=6) Intervention 6 4 Clinical Evaluation 3 Documentation Attentiveness / Surveillance 5 Interpretation 1 Patient Advocacy 2 Medication Administration Prevention

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 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

66 Results – Suggestions to others
Responses from 53 participants were developed into themes: System 10 Team members 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 ADN’s 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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