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

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

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

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

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

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 Board’s SARP

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)

Study Methodology

Sample

# LPNs # RNs Total # LPNs +

RNs

% CY 05 closed complaint cases

44 34 78 12

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”

Study Limitations

• Limited ability to generalize

• Case file not designed for RCA

• Limited consumer-reported errors

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)

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

Factors Associated with Nursing Error: Nurses’ Perception

• Stress/high work volume

• Clinical inexperience

• Unfamiliar practice setting

• Poor judgment

RESULTS: Patient Profile(N = 62)

• Gender: Female

• Average age: 79 years (range: 45 -96 y)

• Most common diagnoses– Dementia – Diabetes

• Insufficient information: Functional abilities and Language

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

Top 3 Nursing Errors

Nursing Error LPN

(n = 44)

RN

(n = 34)

Total

(N = 78)

Medication 23 19 42

Lack of clinical judgment

11 6 17

Lack of professional responsibility/patient advocacy

3 3 6

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

Medication Errors

Possible contributing factors: Individual

• Violation of the “5 Rs and 3 √s”

• Incorrect transcription

• Failure to verify drug allergy

• Knowledge deficit

Medication ErrorsPossible contributing factors: System

• Lack of patient identification

• Novice nurse orientation/preceptorship

• Amoxicillin as emergency stock drug

Medication ErrorsPossible 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

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)60 38 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 0

Clinical Judgment ErrorsPossible 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

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

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

Patient Safety Implications

Medication Administration

• Error potential inherent in process

• Financial and human cost

• Cognitive process

• Consistency in 5Rs and 3√s

• System prompts

Patient Safety Implications

Clinical Judgment

• “Off-shift” expertise to support clinical decision making

• Standardization of hand-off communication

• Learning environment

• Patient safety alerts

Error Prevention Strategies

Error Prevention Strategies

• Individual nurse

• Nursing education

• Systems

CONCLUSIONS

Nurse-perceived factors impacting ability to practice competently:

• Stress/high work volume

• Clinical inexperience

• Unfamiliar practice setting

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

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

CONCLUSIONS

• BON actions in response to nursing errors are punitive…

Perception ≠ reality

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

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

Conceptual FrameworkThreat 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

Conceptual FrameworkThreat and Error Management Model

MethodologyResearch 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

MethodologyPopulation

• 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

Methodology

Instrument

TERCAP (Taxonomy of Root Cause Analysis of Practice Breakdown – Responsibility)

Modified TERCAP

MethodologyTERCAP Revisions• Length• Language• Inter-rater reliability• IRB approval

MethodologyStatistical Analysis

• Frequency distributions• Percentages• Thematic Development

Results – Research Question 1

What is the demographic profile of RNs sanctioned by the Texas Board of Nursing (BON)?

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%0

5

10

15

20

25

25– 34 35– 44 45– 54 55– 64 Over 65

Age of sanctioned nurses

Results – Years Licensed

Years Number Percent

< 5 11 17.7%

5-10 13 21.0%

11-15 11 17.7%

16-20 9 14.6%

21-25 5 8.1%

>25 9 14.5%0

2

4

6

8

10

12

14

< 5 5-10 11-15 16-20 21-25 >25

Years Licensed

Results – Highest Degree

0

5

10

15

20

25

30

Highest degreeDegree Number Percent

Diploma 7 11.30%

Associates 27 43.50%

Baccalaureate 19 30.61%

Masters 8 12.09%

Results – Place of Employment

0

5

10

15

20

25

30

35

40

45Setting Number Percent

Hospitals 43 69.4%

Offices/Clinics 5 8.0%

Home Care 6 9.7%

LTC 5 8.1%

Other 3 4.8%

Results – Position

0

5

10

15

20

25

30

35

40

Number Percent

Direct Care 38 61.3%

Charge 6 9.7%

N. Manager 4 6.5%

Combination: D. C. / Manager

12 19.4%

Results - Employment Outcome

Number Percent

Dismissed/Resign 39 62.9%

Resigned 6 9.7%

Stayed with Emp. 16 25.8%0

5

10

15

20

25

30

35

40

Dismissed/Resign Resigned Stayed with Emp.

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

Results – Research Question 2

• What are the incidences of threats?• Individual• Healthcare Team• Patient• System

• Types of errors?

Results – Individual Factors

Number Percent

Fatigue 14 27%

Inexperience 11 21%

Mental Health 4 8%

Drug/ SA 3 6%

Other 14 27%

Thirty six (69%) selected at least one

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%

Results – Patient FactorsThirty nine (75%) selected at least one

Number Percent

Altered Consciousness 13 25%

Cognitive Impairment 10 19%

Communication Difficulty 9 17%

Other 14 27%

Results – System FactorsForty 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%

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%

Results – Types of ErrorsNumber* Percent

Documentation 28 54%

Medication Administration

23 44%

Intervention 19 36%

Interpretation 18 35%

Attentiveness / Surveillance

16 31%

Clinical Evaluation 16 31%

Patient Advocacy 14 27%

Prevention 11 21%

* Number responding that an error type contributed to the event either “moderately” or “greatly”

Results -- Research Question 3

What are the incidences of the level of harm to the patient?

Results – Level of Harm 

 Number Percent 

No Harm 33 63%

Harm 5 10%

Significant Harm 6 12%

Death 7 13%

Results – Level of HarmWhen 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 6

Documentation 4 4

Attentiveness / Surveillance 3 5

Interpretation 3 1

Patient Advocacy 2 3

Medication Administration 1 3

Prevention 1 2

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?

ResultsTwo 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?

Results – Changes in Practice

System 0

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 11

Responses from 55 participants were developed into themes:

Results – Suggestions to others

System 10

Team members 10

Health care team factors 21

Individual factors 31

Patient factors 1

Specific types of errors 12

Responses from 53 participants were developed into themes:

Results – New Themes

• Use of the word “trust”

• Increased/decreased self confidence

Conclusions

Incidences of threats and types of errors

• Comprehensive identification of factors

• Open ended questions facilitated identification of individual factors

• Documentation issues important

Recommendations

• Nursing Theory

• Nursing Policy

• Nursing Practice

• Nursing Research

RecommendationsNursing 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

RecommendationsNursing 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

RecommendationsNursing 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

RecommendationsNursing 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.