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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.

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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 Nursing."— 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 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 1.Describe characteristics of the nurse, patient, setting 2.Categorize errors and harm outcome 3.Examine cause or contributing factors 4.Identify BRN and employer actions 5.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# RNsTotal # LPNs + RNs % CY 05 closed complaint cases

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 ErrorLPN (n = 44) RN (n = 34) Total (N = 78) Medication Lack of clinical judgment Lack of professional responsibility/patient advocacy 336

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 Probation % response Suspension % response Revocation % response RNs and LPNs (N = 1099)

23 Comparison of ISMP Findings and Actual BON Actions ProbationSuspensionRevocation % ISMP respondent perceived action (N = 1099) % actual CY 05 BON actions in response to all med errors (N = 56) 520


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 3s 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 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 Mary Beth Thomas RN, PhD Perceptions of Registered Nurses Sanctioned by a Board of Nursing: Individual, Health Care Team, Patient, and System Contributions to Error

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 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 AgeNumberPercent % % % % Over %

47 Results – Years Licensed YearsNumberPercent < % % % % % > %

48 Results – Highest Degree DegreeNumberPercent Diploma711.30% Associates % Baccalaureate % Masters812.09%

49 Results – Place of Employment SettingNumberPercent Hospitals4369.4% Offices/Clinics58.0% Home Care69.7% LTC58.1% Other34.8%

50 Results – Position NumberPercent Direct Care3861.3% Charge69.7% N. Manager46.5% Combination: D. C. / Manager %

51 Results - Employment Outcome NumberPercent Dismissed/Resign % Resigned 69.7% Stayed with Emp %

52 Results - Demographics 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 NumberPercent Fatigue1427% Inexperience1121% Mental Health48% Drug/ SA36% Other1427% Thirty six (69%) selected at least one

55 Results – Healthcare Team Factors Forty two (81%) selected at least one NumberPercent Communication2854% Lack of teamwork2344% Inadequate pt. support917% Unwritten unit customs1733%

56 Results – Patient Factors Thirty nine (75%) selected at least one NumberPercent Altered Consciousness1325% Cognitive Impairment1019% Communication Difficulty917% Other1427%

57 Results – System Factors Forty six (88%) selected at least one NumberPercent Communication1121% Environmental1427% Staffing3160% Management factors2344% Back up and support1529%

58 Results – Other System/Team Forty eight (92%) selected at least one Number Percent Lack of team support30 58% High work volume29 56% No breaks7 13% Lack of orientation/training10 19% Conflict with the team15 29% Overwhelming assignments21 40%

59 Results – Types of Errors Number*Percent Documentation 2854% Medication Administration 2344% Intervention 1936% Interpretation 1835% Attentiveness / Surveillance 1631% Clinical Evaluation 1631% Patient Advocacy 1427% Prevention 1121% * 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 NumberPercent No Harm3363% Harm510% Significant Harm612% Death713%

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) Intervention64 Clinical Evaluation36 Documentation44 Attentiveness / Surveillance35 Interpretation31 Patient Advocacy23 Medication Administration13 Prevention12

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 System0 Team members6 Health care team factors12 Individual factors40 Patient factors1 Specific types of errors11 Did not change practice4 No longer work in nursing11 Responses from 55 participants were developed into themes:

66 Results – Suggestions to others System10 Team members10 Health care team factors21 Individual factors31 Patient factors1 Specific types of errors12 Responses from 53 participants were developed into themes:

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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