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

2. 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)

3. 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

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

5. 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.

6. Significance of TERCAP

7. 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.

8. 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.

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

10. 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).

11. 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.

12. 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).

13. 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)

14. 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)

15. 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)

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

17. 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

18. 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.

19. 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.

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

21. 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.

22. 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.

23. 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.

24. 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.

25. 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

26. 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

27. 2011 TERCAP Instrument in WORD Format

28. 2011 TERCAP online Data Entry Screen Shot

29. 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.

30. Acknowledgement

31. 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.

32. 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.

33. 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.

34. 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.

35. TERCAP Contact
Elizabeth H. Zhong Beth Radtke