WHY DO IT? (contd) Discover characteristics of nurses at risk Provide continuity in investigations Increase competence in addressing Practice Breakdown Better understand why errors occur
November 15, 2001: NDBON voted to participate in the NCSBN PBR Study December 2002: Per the SAAG, not required to obtain consent to gather the data Boards files are subject to ND Open Record Law Individual identifiers are not included Analyze aggregate data
2006 – Strategic Plan 2007 – Implemented TERCAP !
INTERNAL OPERATIONS Potential Violation Report Response Form Investigative Case Interview Investigative Case Summary Disciplinary Review Panel Discipline Statistics
LESSONS LEARNED Commitment Shifts focus from name, shame, and blame Culture Change - will take time Dont have to recreate the process