TERCAP Report Mary Beth Thomas, PhD, RN Chair, TERCAP Committee

TERCAP Committee Members Mary Beth Thomas (PhD. RN, Chair) Julia George (MSN, FRE, RN, Board Liaison) Chuck Cumiskey (MBA, BSN) Janet Edmonds (MSN, RN) Marney Halligan (Ed. D., RN) J.L. Skylar Caddell (RN-BC) Ann Ricks (MSN, RN) Melinda Rush (DSN, FNP/ANP, RN) Liz Faber (BSN, RN)

NCSBN TERCAP Supporting Team Maryann Alexander, PhD, RN, Chief Officer Nancy Spector, PhD, RN, Director Elizabeth H. Zhong, PhD, Associate Beth Radtke, MS, Senior coordinator Qiana Hampton, MBA, Administrative assistant

Outline Purpose of TERCAP Key findings from the TERCAP database 2011 TERCAP Instrument Future plan for the development of the TERCAP database

Purpose of TERCAP The TERCAP (Taxonomy of Error, Root Cause Analysis and Practice Responsibility) database is designed to collect the practice breakdown data from boards of Nursing (BONs) to identify the root causes of nursing practice breakdown from the health care system and individual perspectives. This approach will facilitate the development of strategic interventions to ensure the highest safety standards of nursing practice.

Significance of TERCAP

Milestones of TERCAP 1999: NCSBN appointed the Disciplinary Issues Task Force. 2002: Benner, et al., “Individual, Practice, and System Causes of Errors in Nursing: A Taxonomy” was published in JONA. 2006: Benner, et al., “TERCAP: Creating a National Database on Nursing Errors” was published in Harvard Health Policy Review. 2007: TECARP Online Instrument was released.

Milestones of TERCAP (con’t) 2008: TERCAP Online Instrument was revised. 2008: NCSBN hosted the TERCAP Forum in Chicago. 2009: The NCSBN published an introduction book “Nursing Pathways for Patient Safety”. 2011: The first TERCAP report was completed. 2011: The 2011 TERCAP Instrument accompanied by an updated protocol was released.

Distribution of 22 Boards of Nursing Participating in TERCAP Both WV-RN and WV-PN boards submitted their cases.

Case Selection Cases meeting the following criteria are used for the analysis: The case involves a nurse who was involved in the practice breakdown. The case involves one or more identifiable patients. The case results in some types of board action (disciplinary action, alternative program, non- disciplinary action, referral to other agency).

Profile of Nurses Who Committed Practice Breakdown 861 nurses were reported to 20 BONs for having committed practice errors. 83% were female and 17% were male. The average age of the nurses was 46.2 (SD=11.6, n=834), ranging from 21 to 77.

Profile of Nurses Who Committed Practice Breakdown (con’t) Sixty percent of the nurses held RN licenses, 37% held LPN/VN licenses, and 3% of them held multiple licenses (RN and LPN/VN or APRN licenses, while 1% of them were advanced practice registered nurses (APRN).

Profile of Nurses Who Committed Practice Breakdown (con’t) 2010 TERCAP Statistics and License Statistics in 20 Jurisdictions 22% 38% APRN LPN/VN % Composition RN 74% 61% TERCAP Statistics (N=837) State License Statistics (N=1,543,871)

Profile of Nurses Who Committed Practice Breakdown (con’t) Employment Setting Employment Setting % (N) Hospital 38 (331) Long-term Care/Assisted Living 32 (277) Outpatient Setting 17 (147) Behavioral health 3 (27) Other 10 (79)

Profile of Nurses Who Committed Practice Breakdown (con’t) Length of Licensure Years Licensed % (N) Less than 5 years 20 (171) 5 to10 years 17 (148) 11 to 20 years 22 (191) 21 to 30 years 15 (126) Above 30 years 8 (72) Missing 18 (153)

Profile of Nurses Who Committed Practice Breakdown (con’t) Composition of Employment History (N=725)

Employment Status As a result of the current investigation, 56% of the nurses were terminated by their employers, and 7% of them resigned in lieu of termination. Only 28% of the nurses involved remained with their employer. Have you seen this nurse? changing work place Practice Breakdown New Employment State boards have started to address this issues for example Texas….. Additional Practice Breakdown

Individual Factors Contributing to Practice Breakdown 55% of the nurses committed a practice breakdown when they worked in a location for two years or less, but 73% of them had been licensed for two years or longer. 36% of these nurses were previously disciplined and 38% were terminated by their employers for practice related issues in the past. This information was not available in 17% (n=82) of the cases.

Nature of Practice Breakdown Cases Practice Breakdown Categories Practice Breakdown Categories % (N) Lack of Professional Responsibility 77 (665) Lack of Clinical Reasoning 51 (441) Lack of Intervention 50 (434) Documentation Error 44 (380) Lack of Interpretation 40 (343) Medication Error 32 (278) Lack of Attentiveness 25 (219) Lack of Prevention 24 (208) Data were extracted from the TERCAP Database in December, 2010. This report is based the 861 cases that meet the research criterion.

Nature of Practice Breakdown Cases (con’t) Total Number of Practice Breakdown Categories Selected

Nature of Practice Breakdown Cases (con’t) 72% of the cases involved unintentional human errors. 52% of the practice breakdown cases did not cause any harm to patients. 59% of the cases investigated resulted in disciplinary actions, and 23% of the cases were sanctioned non-disciplinary actions.

Summary A statistically significant link between the employment history and the risk of committing additional practice breakdown is established by the current analysis. This finding indicates that the nurses’ employment history can serve as a useful tool to identify a small group of nurses with a high risk of committing violations. We were not able to identify sufficient association between system factors and the practice breakdown, possibly due to constraints in sample size.

Build the Bridge “Changes in health care policy requires the input and action of legislators and officials” who need to “have an in-depth understanding of the nursing practice” (Benner, et al., 2006). To influence health care and nursing policy at local, state, national, and possibly international levels, a national database on nursing practice breakdown is prerequisite. TERCAP will function as a national adverse events database to bridge nursing professionals with public officials and legislators.

Rationale for the 2011 Instrument Update To establish TERCAP as a national database on nursing practice breakdown. To collect more valid data to determine the impact of system factors in practice breakdown. To make the data entry less time consuming. To reduce missing records or selection of “unknown” in data entry. reporting database.

Features of the 2011 TERCAP Instrument Streamlined Shorter Focused Concise Reduced total number of mandatory questions from 64 to 45 Redesigned the questions Revised the protocol

Overview of the 2011 TERCAP Instrument The updated instrument contains 45 mandatory and 17 optional questions Nurse Characteristics Patient Characteristics System Factors Practice Breakdown Optional Questions The updated 2011 TERCAP instrument has significantly reduced the total number of mandatory questions. It was designed to gather information regarding the nurse characteristics, patient characteristics, system factors, and practice breakdown. 17 optional questions are provided at the end of the instrument

2011 TERCAP Instrument in WORD Format

2011 TERCAP online Data Entry Screen Shot

Future Plan Publish the TERAP findings in 2012. Collect 1,000 additional practice breakdown cases by April 2012. Explore the impact of system factors and other unsolved research questions.

Acknowledgement

Participating BONs Texas State Board of Nursing North Carolina Board of Nursing Arizona State Boards of Nurse North Dakota State Board of Nursing Idaho Board of Nursing Minnesota Board of Nursing As of June 7, the total number of TERCAP cases in the Database has reached 1,030.

Participating BONs Kentucky Board of Nursing Oklahoma Board of Nursing Ohio Board of Nursing Alaska Board of Nursing Nevada Board of Nursing New Hampshire Board of Nursing As of June 7, the total number of TERCAP cases in the Database has reached 1,030.

Participating BONs New Jersey Board of Nursing Maine State Board of Nursing Mississippi Board of Nursing Virginia Board of Nursing New Mexico Board of Nursing West Virginia Board of Examiners for Registered Professional Nurses As of June 7, the total number of TERCAP cases in the Database has reached 1,030.

Participating BONs Louisiana State Board of Practical Nurse Examiners West Virginia State Board of Examiners for Licensed Practical Nurses. Arkansas Board of Nursing New York State Board of Nursing As of June 7, the total number of TERCAP cases in the Database has reached 1,030.

TERCAP Contact Elizabeth H. Zhong E-mail: ezhong@ncsbn.org Beth Radtke E-mail: bradtke@ncsbn.org