Quality And Safety Education For Nurses Competencies

  • Read National Council of State Boards of Nursing. Nursing Pathways for Patient Safety 1st ed. St. Louis: MO: Elsevier Saunders. 9780323065177. · Chapter 1 Pages 1-29
  • Research the Institute of Medicine Competencies http://qsen.org/competencydomains/teamwork-and-collaboration/
  • Select and discuss one of  the 5 QSEN(Quality and Safety Education for Nurses  competencies;)

Rubric:

  • Minimum: 300 words minimum and 500 words maximum excluding bibliography
  • APA format
  • 0%plagiarism!!!!

Please see the chapter 1 below :
1 Overview: NCSBN Practice Breakdown Initiative
Kathy Malloch
Patricia Benner
Vickie Sheets
Kevin Kenward
Marie Farrell
Everyone can recall lessons learned from experience. Often the best remembered lessons are the ones that were hardest learned—gleaned from making mistakes and dealing with the fallout from those mistakes. By studying situations where nursing practice breaks down, nurses can learn from the experiences of their colleagues. This is far better than learning from reliving the same difficult experiences (Author Unknown).
Each day, in most health care settings in the United States, nurses monitor and manage the health care patients receive. The goal of these efforts is to ensure that the health care team delivers high-quality and safe patient care. Despite these efforts, missteps occur as do undetected changes in patients’ conditions. These missteps and undetected changes are cause for great concern, and they challenge caregivers to examine their practices, and to create safer practices and ultimately better patient outcomes. The traditional, punitive, blame-placing practices that are found in most health care organizations also give cause for great concern, as those involved in these missteps are often reluctant to report them.
For these reasons (and others described below), the National Council of State Boards of Nursing (NCSBN) launched a national initiative in 1999 entitled the Practice Breakdown Advisory Panel (PBAP). The objective of the PBAP was to study nursing practice breakdown, to identify common themes related to those events, and most importantly, to recommend strategies to individuals, teams, and organizations to correct unsafe conditions and practices. This work would then assist boards of nursing to shift the focus from blame and punishment to prevention, remediation, and correction. Punishment would be limited to those cases of willful negligence and misconduct.
Since its inception, the PBAB has worked with representatives from its 60 member boards and with its consultant, Dr. Patricia Benner, to develop an initial minimum data set on practice breakdown reported to state boards of nursing. The goal was to develop an instrument that can distinguish human and system errors from willful negligence and intentional misconduct, while identifying the area of actual nursing practice breakdown in relation to core goals and standards of good nursing practice. An additional and equally important aim was to serve as a guide to increase the skills and competence of regulatory professionals in addressing practice breakdowns.
GOALS OF THE INITIATIVE
The goals of studying practice breakdown are to develop a consistent approach to assessing patient safety and reporting errors that will increase knowledge and incentives for error detection, reporting, and prevention while fulfilling the duty to protect the public from unsafe practices. These goals constitute a paradigm shift that reframes the focus from the individual, the nurse, to one that emphasizes prevention and the implications for the health care system, the health care team, and the individual nurse. The mechanism for achieving these goals was to create a standardized data collection instrument for investigators throughout the United States who carry responsibility for examining incidents of practice breakdown. The instrument, described below, is entitled Taxonomy of Error, Root Cause Analysis, and Practice Responsibility, or “TERCAP®.” The PBAP also created additional products and initiatives that are discussed in this chapter.
FOCUS OF THE BOOK
This book presents an overview of the work that the NCSBN has undertaken to assist others committed to improving patient safety. The elements of this initiative include a framework for analyzing practice breakdown, the data collection instrument TERCAP, and selected tools and practices to implement its use.
This framework and ways of thinking about practice breakdown are useful not only for boards of nursing but also for nursing students, faculty, nurses in practice, hospital and other health care administrators, and other accrediting and regulatory agencies that oversee and support the practice of nursing. It is expected that this framework and way of thinking will also be useful to policy makers and those developing, refining, and reframing nurse practice acts. Finally, this work provides the evidence and creates an infrastructure for a major change in the way nurses conceptualize and manage practice breakdown.
PATIENT SAFETY: A DEFINITION
Cooper et al. (2000) describe patient safety as “… the avoidance, prevention, and improvement of adverse outcomes or injuries stemming from the processes of health care (errors, deviations, accidents) …” (National Patient Safety Foundation, 1999, pp. 1–2) and suggest that improving safety depends on learning the ways in which safety emerges from interactions of the components. Woods calls for “… research that matters … to identify critical success factors by moving beyond morbidity and mortality (dedicating a) larger role to functional status, caregiver burden, satisfaction with care, costs of care and cost-effectiveness” (Woods, 2004).
RATIONALE FOR THE INITIATIVE
Members of the NCSBN have expressed, for quite some time, concerns about the lack of evidence for the discipline and began to examine discipline practices from an anecdotal perspective in the 1990s. Concern persisted for the value of board sanctions such as probationary mandates, official censure, and nondisciplinary letters and their relationship to nurse behavior. Board members and staff are uncertain about whether the discipline imposed provided the intervention to effect improvement in practice behavior. The PBAP was formed in 1999 because of these concerns. Further, around this time, the Institute of Medicine (IOM) began publishing its work on patient safety.
INSTITUTE OF MEDICINE REPORT
There have always been medical and nursing errors, and these errors have always been of concern to both practitioners and patients. In 1998 the IOM captured the attention of both the media and the public when it published its landmark report To Err Is Human (Kohn et al., 2000) and identified the pervasive reality of errors related to health care. Since then, patient safety has become an overriding concern of the public at large, and some characterize this concern as a crisis of faith.
The IOM produced a second report in the fall of 2004 entitled Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004). Several aspects of the report include implications for research in practice breakdown. Of particular interest is Recommendation 7-2.
The NCSBN, in consultation with patient safety experts and health care leaders, should undertake an initiative to design uniform processes across states to better distinguish human errors from willful negligence and intentional misconduct, along with guidelines for their application by state boards of nursing and other state regulatory bodies having authority over nursing (Page, 2004).
In the United States, the most appropriate place to examine this phenomenon would occur at the state level, through the state boards of nursing. This is because these boards are charged with the task of addressing key issues that are informed by the principles that guide their actions.
THE WORK OF BOARDS OF NURSING
The work of boards of nursing in the United States is complex for several reasons:

  • 1The primary obligation of boards of nursing is to protect the public through effective delineation of the scope of practice, licensure, certification, and discipline.
  • 2The public/patient should be protected from unsafe institutional design and policies that impede or prohibit safe, effective nursing care. Boards of nursing must distinguish between system, individual, and practice issues before determining the actual violation of a nurse practice act. For example, organizational system processes within health care settings often result in suboptimal or even forced choices between competing justified needs and demands of good patient care. Negative outcomes for some patients may come at the expense of meeting the crisis or emergency intervention requirements of other patients.
  • 3Evidence for effective professional accountability needs to be established. Effective decision-making results when the nurse recognizes the fiduciary/advocacy responsibility she/he has for the patient and is able to meet those responsibilities by adequate safe institutional design, orientation, and ongoing in-service education, staffing, and policies.

CUTBACKS, NURSING SHORTAGES, REDUCED HOSPITAL STAYS
Suboptimal institutional environments impede safe patient care. Many complex elements have contributed to this current crisis of faith in the health care system. Specifically, these elements in the form of errors came to the forefront as health care institutions implemented cutbacks in nurse-patient staffing ratios, increased nursing workload, overtime, and temporary employees. These cutbacks were exacerbated by the trend of shorter hospital stays for patients who were acutely ill and, in turn, some of the checks and balances that helped ensure patient safety were also eliminated. The nursing shortage further complicates the situation. This is partly because the complexity that results from reduced time for hospital stays and its concomitant compressed time allotment requires not only more nurses but nurses with higher levels of competence to assess, synthesize, and coordinate patient care needs.
CREATING A FAIR AND JUST HEALTH CARE CULTURE
Concerned health care organizations have recognized the complexity of these trends and their impact on practice breakdown. They worked to shift a health care culture that emphasized blaming the individual to one that looked to improve performance of the system and to reduce systems errors. Some experts have called for a no-blame culture as the solution to the problems resulting from fear and intimidation from error management. Much has been written about these no-blame cultures, viewed as a key mechanism to reduce errors and as an approach to what has evolved as a patient safety movement.
Most health care professionals recognize that shame, blame, and punishment for mistakes do not improve patient safety. In many situations, patient safety is compromised as situations are not fully analyzed and corrected for fear of further punishment. Many now recognize that a nonconstructive position is one in which an either-or position is taken—that is, where either the individual or the system is determined to be at fault, or where the system is always at fault and the individual is the victim. Rather, the desired expectation is a culture characterized by fairness and justice.
just culture for practice breakdown management is one in which the reality of the environment, organizational cultures, and missteps are viewed as critical learning opportunities for patient safety, while also addressing carelessness, inattentiveness, and substandard practice as well as intentional misconduct in any work environment (Marx, 2001). The goal is to avoid the tendency to blame individuals for patient safety issues when the error is unintentional and is usually a product of many forces and mishaps that led to the practice breakdown. However, a just culture demands attention, repair, remediation, and discipline of those professionals who willfully ignore their professional standards. A just culture requires mutual support for a difficult and complex job, accountability for meeting the standards of good practice by all workers, and rigorous attempts to protect the public from unsafe practices. An additional goal is to avoid the tendency to blame individuals for patient safety issues when, in fact, more factors are involved than one person’s actions alone. Shared practice responsibility is a critical consideration in addition to separate considerations of the individual and the health care system’s contributions to practice breakdown.
An oppositional argument about either an individual or a systems approach is wrongheaded, since both are required in addition to carrying out the notions of good and upholding the standards of good practice of any person who is a licensed professional (Benner et al., 2002; Page, 2004). Such an oppositional view usually posits the individual as an isolated individual rather than a member-participant of a professional practice community that has publicly made a commitment to uphold the notions of good and standards of a particular profession. If the individual imagined is a competitive individual (as in an extremely competitive business model), then there can be no accounting for the moral sources and collective standards of practice, commitment to good practice, skilled know-how, ethos, and participation in the formative outcomes of an accredited professional educational program. Accrediting bodies such as the State Board of Registered Nurses accredit schools of nursing for imparting skilled know-how, knowledge of the discipline, and ethical comportment, which includes both self-improving practice and safe practice. Rather than thinking of the individual as self-maximizing or competitive, in a professional practice one needs to think of professionals (nurses, doctors, lawyers, clergy, etc.) as members-participants of the profession, committed to the notions of good internal to the practice (MacIntyre, 1984) and formed by their educational processes to have a fiduciary responsibility to their patients, clients, and parishioners.
Yet, Page (2004) and her colleagues point out:

  • …An extreme systems perspective that recognizes no individual contributions to patient safety presents problems such as “learned helplessness” and failure to address instances of individual deficits in competencies or willful wrongdoing. With regard to the phenomenon “learned helplessness” …health care practitioners may be tempted to lessen their personal vigilance and striving for personal excellence and think, “It’s the system—there is nothing I can do about it.” But safe and effective care depends upon each professional continuing the struggle under less-than-ideal local circumstances (Reason, 1997 [as cited by Page, 2004, p. 31]).

If it were possible to make medicine absolutely scientific technical certainties with no unresearched aspects and no great individual variations in patients or in diseases/injuries, then a closed system designed to be “error free” would be possible, as is the case for manufacturing processes that are functioning well under tightly controlled circumstances. But medicine and nursing require professionals who are well educated, skillful, and ethically committed to patients’ well-being because professional skill and judgment are required, even as the best scientific evidence for practice is used. Medical and nursing clinical situations, unlike well-controlled manufacturing processes, are underdetermined, open ended, and highly variable, and therefore require highly professional judgment and skilled know-how by nurses and physicians who are committed to act well on behalf of the patient’s best interests. Systems in health care delivery are open systems. In health care, systems engineering focuses on the structures, processes, and functions of an open living system in relation to inputs and outcomes. Constant input related to knowledge, science, skill, repair, and redesign is needed for open systems. Systems analysis captures what has already happened as a result of system failure or breakdown; therefore systems repair is post hoc related to a past failure, and future oriented in designing a better system to prevent future similar failures. Professional practice communities are required to shore up and prevent immediate failure or intervene immediately in a present practice breakdown. All human systems require ongoing repair and redesign by individuals and practice communities who work together to sustain a self-improving practice.
As technology proliferates and makes work less transparent, so does the likelihood for new types of errors (Page, 2004; Reason, 1990). It is no longer possible for any one clinician to know and/or remember all the needed information for practice as noted by the Quality Chasm Report (Committee on the Quality of Health Care in America, 2001):

  • Today, no one clinician can retain all the information necessary for sound, evidence-based practice. No unaided human being can read, recall, and act effectively on the volume of clinically relevant scientific literature (pp. 4445). Relying on memory has become a hazard for patient safety as the amount and complexity of information continues to grow. Nurses need to be aided with information systems and decision aid systems (Page, 2004).

SHARED PRACTICE RESPONSIBILITY
All professions have the responsibility to be self-regulating and self-improving. All member participants of a professional practice have a shared public and civic responsibility to uphold the standards of the practice and to practice in such a way as to ensure ongoing improvement in the practice. Professional practice is never upheld by one individual practitioner alone. It relies in part on institutional conditions to enable good practice through system level infrastructures and organizational planning and integrity. It also relies on cooperation and collaborative effort among health care professionals who live up to the notions and standards of good practice. Complex professional practice relies on ethical, knowledge-based, and skillful practice by professionals who use clinical judgment in underdetermined clinical situations. Practice communities develop and share local practice knowledge, standards, and norms, and uphold these as members of both the local professional practice community and their larger professional communities of nursing or medicine.
The professional practice of nursing is a socially organized discipline in which its participants have been educated and tested for licensure. Professional nurses carry responsibilities to each other and to other health care team members to uphold the notions of good practice. They hold these standards of good practice in common within nursing and with other interdisciplinary team members such as physicians, pharmacists, respiratory therapists, and social workers. Professionals, by definition, have entered into a covenant to act as responsible, professional citizen members in education, licensure, and practice and through participation in professional associations (Sullivan, 20042005).
The PBAP considers these professional dimensions and the relationships among the individual, the health care team, and the health care system. These elements interact in ways that honor and integrate self-governing, socially organized practice members who work professionally to participate in the everyday practices of a health care delivery team. However, a serious oversight occurs when these relationships and shared professional talents and commitments are not considered in an examination of errors. Reporting and preventing errors in any profession are serious expectations for all members of self-improving professional practice. Professional practice is impossible without these shared expectations.
THE DESIRED OUTCOME
Administrators and leaders need to support health care cultures that value questioning practices, collaborating on challenges to the health care team, and pursuing activities to promote professional development. Woods described the “holy grail [of research] that everyone wants but no one has” to include:

  • 1A measure of nurses’ work
  • 2Descriptive studies of nursing-related error
  • 3Safer and more effective work processes and work spaces (supported by information technology)
  • 4A standardized approach to measuring patient acuity
  • 5Safe staffing levels based on outcomes in different types of nursing units
  • 6Effects of successive workdays/sustained work hours on patient safety
  • 7Descriptive studies of levels of education, preparation, and outcomes
  • 8Models of collaborative care, including care by multidisciplinary teams (Woods, 2004)

BOARDS OF NURSING AS SOURCES OF DATA
Boards of nursing possess a potentially rich source of data that could examine sources of nursing error and thus are well positioned to add to the body of knowledge surrounding this aspect of health care errors. This is, in part, because the kinds of errors typically reported to boards of nursing are usually serious in nature, and the knowledge from these examinations provides descriptive studies of nursing-related error. Further, the data from these studies hold great potential for developing more effective strategies to prevent and reduce serious errors at the institutional and professional practice levels.
Boards of nursing have access to data from educational and service settings. Board members can examine aggregate data and the disciplinary actions that arise from both of these settings. These reviews provide a more complex but meaningful set of data than if the service setting or the educational setting alone were the focus of examination. By studying practice breakdown, boards can promote patient safety and prevention of error by identifying nurses and nursing situations at risk for potential practice breakdowns. This new preventive regulatory role promotes proactive regulation before harm occurs rather than waiting to discipline after problems are reported.
Under the supervision and quality control of the NCSBN, this national database of nursing errors reported to state boards of nursing could become a source of additional research studies conducted by researchers, including graduate students, who want to examine practice breakdown and patient safety. For example, an outside researcher might want to focus on errors associated with the administration of medications or practice breakdown episodes related to nursing interventions, either failure to intervene or inappropriate intervention. Any of the elements or all areas of nursing practice areas could be compared locally, regionally, and nationally in order to better understand the causes of practice breakdown in nursing. This database could also shed light on a particular state’s or a particular type of institution’s comparisons of errors and patient harm with the national database. The NCSBN will encourage such outside research projects, and provide oversight and quality control as such studies evolve.
By going public and making the regulatory work of state boards of nursing more transparent to staff nurses and student nurses, the NCSBN hopes to encourage primary prevention of practice breakdown and draw attention to the central role of safety work that has long been a hallmark of nursing practice (Benner, Hooper-Kyriakidis, & Stannard, 1999). By systematically understanding the regulatory functions of the nursing profession and the major kinds of errors that nurses are likely to be involved in at some point in their careers, nurses will be better prepared to respond appropriately to practice breakdown through accurate documentation, reporting, truth telling, and immediate measures to minimize harm to the patient. The situations reported to the state boards of nursing are typically more harmful to patients, fall outside the standards of good practice, involve knowledge-skill deficits, and in those ways differ significantly from errors that would never be reported to state boards of nursing. For example, the following medication error that occurred early in the nursing career of Dianne Pestolesi, who was on the nursing faculty (Benner et al., in press), is a classic kind of error that would not be reported to the state board because the nurse took all the appropriate actions, notified the physician immediately, addressed the potential harm to the patient by altering her care, and successfully prevented the potential harm to her patient:

  • I was to give Synthroid IV to a woman who was hypothyroid. I thought the order was a very large dose. When the vials came up there were three vials to be reconstituted, which again made me think that this is too large of a dose, so I called the pharmacy and the pharmacist said, “Well it is a large dose, but it is within the possible range of dosages.” I had this icky feeling that it wasn’t right. I went to the patient and as I was pushing the IV med in, again, I had this icky feeling that it was the wrong dose. So I then went back to the chart and looked at the doctor’s order, which I had not done, but should have done from the beginning. And it was an error. I had given the patient three times the amount of the drug that was intended. I went hot and cold. I thought well this is the end of my nursing career! I would lose my license. I called the doctor and told him about the error. “I am really sorry; I have made a terrible medication error. I gave your patient three times the dosage of Synthroid that was ordered. What can I do to help this patient? He said to watch her closely for arrhythmias and to carry Inderal in my pocket, ready to administer it to her if she had a tachycardia. I arranged with the other nurses to watch my other patients while I stayed in the patient’s room. The patient became very antsy, and very hot then, for the first time after surgery needed to have a bowel movement. The patient dramatized all the symptoms of hyperthyroid. I fanned the patient. I put a cool cloth on her head, and stayed with her. Her pulse stayed below 120. She came through it without arrhythmias, but I will never give the wrong dose of Synthroid again. I will always check the original order and call the doctor if I have questions. I will never go against my instincts, overriding my icky feeling that this is not right. I learned that I could survive and continue to be a nurse, even though I made a terrible error. I am grateful that the patient came through OK. I filled out an incident report at the end of the shift (Benner et al., Chapter 4, in press).

Ms. Dianne Pestolesi, RN, MSN, now tells this story to her students as a cautionary tale. She is equally vivid in describing her own foreboding and fears for the patient, and the patient’s actual responses. She acted responsibly and took responsibility for learning from her error. She points out to her students that she now attends to the usual match between range of dose and packaging of the medication. She was a newly graduated nurse when this incident occurred and did not yet attend to her growing practical experiential knowledge. She models for her students the most ethical response to an error. She made no effort to hide her mistake, which always compounds any error and increases the consequences for making the error. If the patient, public, and health care team members cannot trust the accuracy of documentation of care given and doses of medication given, then the patient is placed in a situation of potential further harm. Wu (2000) proclaims that providers who make an error, particularly an error that causes harm, are “the second victim” of the error.
In the context of a “shame and blame” culture, errors are more likely to be covered over, and the one committing the error is tempted to remain silent and avoid telling the patient (Wu et al., 1991). However, all these responses lack integrity and expose the patient and health care team—including the one making the error—to even more harm. Had Dianne Pestolesi covered up her error, not called the physician, and not charted this overdose, she likely would have been reported to the state board of nursing for endangering a patient. She herself would have become a victim of guilt and remorse. While she regretted her error, she took steps to avoid ever making the same mistake again by honestly reporting the error immediately and following through with protective attentive care of her patient until she was through the resulting “thyroid storm” of the high dosage. She now uses her example to let students know that everyone can and will make an error without intending to, and responding with integrity is the only possible way forward.
It is impossible to prevent all errors. Members of highly reliable organizations who also engage in high-risk work imagine all the possible pitfalls and errors that might occur (Weick & Sutcliffe, 2001). This turns out to increase the reliability of performance when it spurs persons in the highly reliable organization to imagine and correct potential errors and to take seriously and act preventively when “near misses” occur. It is an opposite response to a culture of low expectations (Reason, 1990Wachter, 2008Wachter & Shojania, 2004) where mistakes such as misspelling of patient names, misidentification, or underreporting of procedures are common and thus commonly overlooked as a basis for further checking. This book will contain many actual cases and cautionary tales that we hope will assist staff nurses, administrators, and student nurses in preventing recurrence of the kinds of practice breakdowns that commonly occur in nursing.
This book seeks to augment the excellent educational initiative to improve the education of undergraduate and graduate nurses about improving patient safety, sponsored by the Robert Wood Johnson Foundation and led by Linda Cronenwett. This project, Quality and Safety Education for Nurses (QSEN) (www.QSEN.org), seeks to improve education in quality improvement and patient safety in nursing education. Cronenwett and colleagues (Cronenwett et al., 2007) acknowledge that patient safety is firmly lodged in the nursing tradition and summarize some of the goals of their project as follows:

  • At the core of nursing lies incredible historical will to ensure quality and safety for patients. Many current endeavors, such as the work occurring in the Robert Wood Johnson Foundation–sponsored project, Transforming Care at the Bedside, demonstrate how quality/safety/improvement work attracts the hearts of nurses, resulting in the “joy in work”1 Developing health professionals capable of continually improving health care quality, safety and value: The health professional educator’s work1 that retains the health care workforce. Attending to the development of QSEN competencies may help nurses—who love the basic work of nursing—love their jobs, too (Cronenwett et al., 2007, p. 122).

TABLE 1.1 Institute Of Medicine Competencies

PATIENT-CENTERED CARE
Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs
http://qsen.org/competencydomains/teamwork-and-collaboration/
TEAMWORK AND COLLABORATION
Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care
EVIDENCE-BASED PRACTICE
Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care
QUALITY IMPROVEMENT
Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
SAFETY
Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance
INFORMATICS
Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making
Copyright © 2007 QSEN. All rights reserved. Available at http://qsen.org

Table 1.1 lists the definitions of the IOM competencies for nursing and the knowledge skills and attitudes that were developed in the QSEN project for curricula in undergraduate nursing based on these competencies.
1 Batalden, P. (2005). Developing health professionals capable of continually improving health care quality, safety and value: The health professional educator’s work. Available at http://www.QSEN.org. Accessed October 22, 2008.
CONCEPTUAL FRAMEWORK
In developing the nursing taxonomy of error, we inductively identified nursing practice breakdowns that were reported to a state board of nursing that were considered to fall within the very general rubric of “clinical judgment.” Because this rubric proved to be so inclusive in an earlier classification study conducted by the state board, and because there was particular diversity and challenge in developing the range of corrective measures that were required for this very large category of nursing practice breakdown, we decided to inductively generate a taxonomy of nursing practice breakdown within reported cases that had been classified as breakdowns in clinical judgment in the past. Working back and forth from commonly held notions of good nursing practice and the cases of practice breakdown, the PBAB generated the categories of nursing practice breakdown based on breakdowns in usual standards of good nursing practice, which inherently contain areas of patient safety work The conceptual framework that informed this study focuses on the aspects of nursing practice to which nurses attend when care is planned, practiced, and evaluated as expected (Table 1.2). Within these three, the following standards of good nursing practice are identified.
SAFE MEDICATION ADMINISTRATION
The nurse administers the right dose of the right medication via the right route to the right patient at the right time for the right reason.
DOCUMENTATION
Nursing documentation provides relevant information about the patient and the measures implemented in response to their needs.
ATTENTIVENESS/SURVEILLANCE
The nurse monitors what is happening with the patient and staff. The nurse observes the patient’s clinical condition; if the nurse has not observed a patient, then he/she cannot identify changes if they occurred and/or make knowledgeable discernments and decisions about the patient.
TABLE 1.2 Patient-Centered Care

Definition: Recognize patient or designee as source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs
Knowledge Skills Attitudes
Integrate understanding of multiple dimensions of patient centered care:

  • •Patient/family/community preferences, values
  • •Coordination and integration of care
  • •Information, communication, and education
  • •Physical comfort and emotional support
  • •Involvement of family and friends
  • •Transition and continuity
Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care
Communicate patient values, preferences, and expressed needs to other members of health care team
Value seeing health care situations “through patients’ eyes”
Respect and encourage individual expression of patient values, preferences, and expressed needs
Value the patient’s expertise with own health and symptoms
Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values Provide patient-centered care with sensitivity and respect for the diversity of human experience Seek learning opportunities with patients who represent all aspects of human diversity
Recognize personally held attitudes about working with patients from different ethnic, cultural, and social backgrounds
Willingly support patient-centered care for individuals and groups whose values differ from own
Demonstrate comprehensive understanding of concepts of pain and suffering, including physiologic models of pain and comfort. Assess presence and extent of pain and suffering
Assess levels of physical and emotional comfort
Recognize personally held values and beliefs about management of pain or suffering
Elicit expectations of patient and family for relief of pain, discomfort, or suffering Appreciate role of the nurse in relief of all types and sources of pain or suffering
Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs Recognize that patient expectations influence outcomes in management of pain or suffering

CLINICAL REASONING
Nurses interpret patients’ signs, symptoms, and responses to therapies. Nurses evaluate the relevance of changes in patient signs and symptoms, and ensure that patient care providers are notified and patient care is adjusted appropriately. All nursing care requires clinical judgment, but for the purposes of capturing errors related to clinical judgment, this work limits the definition of practice breakdown associated with clinical reasoning to those events related to inadequate titration and adjustment of therapies and therapeutic actions based on the patient’s responses to those therapies. The attempt is to capture the increasing importance of nurses’ adjustment and titration of therapies based on the patient’s responses.
PREVENTION
The nurse follows usual and customary measures to prevent risks, hazards, or complications due to illness or hospitalization. These include fall precautions, preventing hazards of immobility, contractures, stasis pneumonia, and more.
INTERVENTION
The nurse properly carries out nursing actions.
INTERPRETATION OF AUTHORIZED PROVIDER ORDERS
The nurse interprets and translates into action authorized provider orders.
PROFESSIONAL RESPONSIBILITY/PATIENT ADVOCACY
The nurse demonstrates professional responsibility and understands the nature of the nurse-patient relationship. Advocacy refers to the expectations that a nurse acts responsibly in protecting patient/family vulnerabilities and in advocating to see that patient needs or concerns are addressed (Benner et al., 2006).
It is both notable and understandable that these inductively generated areas of nursing practice are all central to both the occurrence and prevention of patient care breakdown since nursing practice has a long tradition of patient safety work as central to the everyday nursing practice (Benner, Hooper-Kyriakidis, & Stannard, 1999).
Prior to the development of the report Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004), the focus had been on epidemiology of health care errors and quality improvement in the safety for systems of delivery of health care (Aspden et al., 20042006Committee on the Quality of Health Care in America, 2001Greiner & Knebel, 2001Kohn, Corrigan, & Donaldson, 2000). In 2004 (Page, 2004), the focus was on the problematic work environments of nurses, environments that often force errors through short staffing, excessive work overtime, frequent interruptions of nurses’ work, lack of use of informatics focused on safety, high pressure for efficiency and productivity, and so on. Stone et al. (2007) examined the relationship between nurse staffing and hospital characteristics and specific patient safety measures, such as nosocomial infection rates and incidence of decubitus ulcers. They found that higher nurse-to-patient ratios and increased overtime diminished patient safety outcomes and increased in-hospital mortality rates. TERCAP seeks to capture aspects of the work environment that contribute to nursing practice breakdown.
The safety work of nurses and physicians is intertwined, and their roles often overlap. But the focus and clinical “know-how” of the two professions remain as a built-in cross-check for patients when the work and health care team cultures are collaborative and synergistic. For example, the success of “checklist” strategies for improving patient safety often rely on physician and nursing performance, but the nurse who typically has more continuous time with the patient and in the health care delivery setting is the key to making checklists work on a daily basis. Gawande, in an article published in The New Yorker in 2007, points to Peter Pronovost’s efforts and demonstrated success in improving quality of patient care through the use of checklists. Checklists deal with forgetfulness and the hazards of relying on memory for everyday performance of routine safety and quality work. Often health care providers do not understand the safety and quality implications inherent to protocols, and thus skip them. Gawande (2007) describes nurses’ contributions to the success of the use of patient safety checklists:

  • One [Checklist] aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from 41% to 3%. [Another tested checklist ensured] the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers.2 The proportion of patients who didn’t receive the recommended care dropped from 70% to 4%; the occurrence of pneumonias fell by a quarter; and 21 fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half (p. 5).

Gawande also points out that it was the nurses who monitored the checklists, keeping them current and effective.
Gawande’s (2007) article points out the increasingly central role that nurses play in quality improvement and patient safety. He also points to the challenges of increasing complexity in nursing, and medicine has compounded the problems with safety work in the hospital. Nurses in acute care settings, and particularly in intensive care units, have many exposures to risks of errors daily because of the number of patient interventions they perform daily.
Practice breakdown is the disruption or absence of any of the aspects of good practice. It occurs when individuals, the health care team, or the health care system do not attend to one or more of these central aspects of nursing practice that each contribute to patient safety and quality improvement work.
Reason (1990) provided a way to think about errors at the organizational and systems levels. When weak points and holes within an organizational system line up, errors occur more often. For example, a hierarchical system with steep lines of authority and emphasis on top-down one-way communication creates a system that is prone to errors. Add production pressures, lack of procedures to double-check patient identification, or read back plans for verification, along with a “culture of low expectation” (“people often get it wrong here, nothing unusual to worry about, no further checking is warranted”) can line up much like holes in a stack of Swiss cheese. The error did not start out to be an error, but it was supported by a careless aggregation of lack of safety checks, poor communication, and time pressure.
Reason’s model was derived from many accident studies in aviation, nuclear power, and complex organizations. He pointed to the importance of seeing the multiple layers of Swiss cheese with large holes, the large holes indicating lack of multiple layers of protection and poor safety system design. A focus on the individual alone at the sharp end of the error parallels the days before automobiles were designed for safety. The driver was admonished to drive carefully in a dangerously designed device that had no built-in protection systems such as air bags, safety belts, roll bars, and so forth. The holes in the system can be considered the root cause of the conditions for the possibility of the error.
We followed Charles Vincent’s framework for root cause analysis in identifying the system contributions to errors. Vincent’s framework is displayed in Table 1.3. We included Vincent’s institutional organization and management; work environment, team, individual staff member(s) task, and patient in the TERCAP instrument (see TERCAP, available at www.NCSBN.org).
TABLE 1.3 Framework of Factors Influencing Clinical Practice and Contributing to Adverse Effects*

Framework Contributory Factors Examples of Problems That Contribute to Errors
Institutional Regulatory content
Medicolegal environment
Insufficient priority given by regulators to safety issues; legal pressures against open discussion, preventing the opportunity to learn from adverse events
Organization and management Financial resources and constraints
Policy standards and goals
Safety culture and priorities
Lack of awareness of safety issues on the part of senior management; policies leading to inadequate staffing levels
Work environment Staffing levels and mix of skills
Patterns in workload and shift
Design, availability, and maintenance of equipment
Administrative and managerial support
Heavy workloads, leading to fatigue; limited access to essential equipment; inadequate administrative support, leading to reduced time with patients
Team Verbal communication
Written communication
Supervision and willingness to seek help
Team leadership
Poor supervision of junior staff; poor communication among different professions; unwillingness of junior staff to seek assistance
Individual staff member Knowledge and skills
Motivation and attitude
Physical and mental health
Lack of knowledge or experience; long-term fatigue and stress
Task Availability and use of protocols
Availability and accuracy of test results
Unavailability of test results or delay in obtaining them; lack of clear protocols and guidelines
Patient Complexity and seriousness of condition
Language and communication
Personality and social factors
Distress; language barriers between patients and caregivers

* Based on Vincent et al. (1998). Framework for analyzing risk and safety in clinical medicine. BMJ, 316(7138), 1154-1157.
We anticipate that as patient safety and quality improvement develops, revisions and additions to TERCAP will be made. Eventually we will need to consider the evidence on the best practices for patient safety and quality improvement. For example, I-SBAR (an acronym that stands for Introduction of caregivers and patients; Situation—a brief statement of the problem; Background relevant for the situation at hand, Assessment—summary of what the clinician believes is the underlying cause and its severity, and Recommendation—what is needed to resolve the situation) (Pope, Rodzen, & Spross, 2008) has been shown to be successful in reducing communication barriers when used by rapid response teams and is promoted by the Institute for Healthcare Improvement as a communication method (IHI website, http://www.ihi.org/ihi). Nurses are in an excellent position to evaluate the use of quality improvement measures designed to improve communication and strategies such as checklists to ensure continuity and consistency among the health care team in performing patient safety protocols.
2 Since the writing of this chapter, antacids in the form of proton-pump inhibitors have been found to increase ventilator acquired pneumonia by 30%. Herzig, S.J., Howell, M.D., Marcantonio, E.R. (2009). Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 301(20): 2120-8.
STUDY QUESTIONS
The PBAP was created to facilitate the exploration in the future of the following study questions based on the definition of safety and the conceptual framework of the study:

  • 1What patient characteristics are associated with different types of practice breakdown?
  • 2What nurse characteristics (demographic data) are associated with different types of practice breakdown?
  • 3What scheduling, staffing levels, and timing of incidents are associated with different types of practice breakdown?
  • 4Which nurses of different licensure types are associated with different types of practice breakdown?
  • 5What educational characteristics are associated with different types of practice breakdown?
  • 6What types of health care institutions are associated with different types of practice breakdown?
  • 7What types of health care system factors are associated with different types of practice breakdown?
  • 8What types of health care team factors are associated with different types of practice breakdown?
  • 9What clusters of practice breakdown are associated with primary nursing types of error?
  • 10What types of practice breakdown are associated with patient harm?
  • 11What types of patient medical record documentation are associated with different types of practice breakdown?

OPERATIONAL DEFINITIONS
The PBAP developed and used a set of operational definitions (see TERCAP Code Book, available at www.NCSBN.org).
ASSUMPTIONS
The PBAP assumed that:

  • 1Data were collected by investigators that included nurses and non-nurses.
  • 2Confidentiality of all records would be maintained in accordance with national and state policies.
  • 3Data were collected and integrated within the context of the investigator’s customary and usual intake processes.
  • 4Data were collected through electronic entry.
  • 5Data were reported accurately and honestly.
  • 6The data collection instrument developed would not add a document to the current process; rather, it would enhance and integrate the existing system of inquiry.

SETTING
The setting for this study was the health care practice settings within the jurisdictions of state boards of nursing throughout the United States. The PBAP collected data regarding the development of TERCAP during a pilot study conducted between April and May 2005.
STUDY DESIGN
The PBAP’s goal was to create a valid, reliable, standardized, data collection instrument that investigators would use to examine practice breakdown and error in the health care workplace. The initial challenge was to identify the major types of nursing practice breakdown and to create a taxonomy of these distinct kinds of practice breakdown, and to examine causes common to situations in which safety was at risk and in which error occurred. Such a taxonomy overlaps with a “A Taxonomy of Medical Errors Made by Physicians,” described in Table 1.4, but has additional types of error related particularly to nursing care.
The research design included a qualitative descriptive case study analysis over a period of 6 years and four reviews of actual cases at the state level. The PBAP derived the taxonomy through repeated analyses of 109 cases and identified 10 sections that informed the parts of the data collection instrument TERCAP (see TERCAP, available at www.NCSBN.org). The research design subsequently included initial and follow-up assessments of TERCAP that resulted in documentation on the data collection instrument (described below).
TABLE 1.4 Taxonomy of Medical Errors for Physicians

TYPES OF ERRORS
Diagnostic

  • •Error or delay in diagnosis
  • •Failure to use indicated tests
  • •Use of outmoded tests or therapy
  • •Failure to act on results of monitoring or testing
Treatment

  • •Error in the performance of an operation, procedure, or test
  • •Error in administering the treatment
  • •Error in the dose or method of using a drug
  • •Avoidable delay in treatment or in responding to an abnormal test result
  • •Inappropriate (not indicated) care
Preventive

  • •Failure to provide prophylactic treatment
  • •Inadequate monitoring or follow-up treatment
Failure of communication
Equipment failure
Other system failures
Data from Leape, L.L., Lawthers, A.G., Brennan, T.A., Johnson, W.G. (1993). Preventing medical injury. Quality Review Bulletin, 19(5), 144-149.

SAMPLE
The membership of the PBAP was developed deliberately to include representatives of boards of nursing throughout the United States and an internationally recognized expert in the topic under investigation. Its membership was also designed to include nurses with expertise at the state level with extensive experience in dealing with practice breakdown. This expert panel reviewed the cases and used repeated examinations to establish the instrument’s validity, reliability, and other essential qualities.
DATA COLLECTION INSTRUMENTS
PURPOSE AND DESCRIPTION
TERCAP is a 60-item electronic data collection instrument. Its purpose is to assist boards of nursing in collecting data using uniform processes across states to examine different patterns of errors and to distinguish practice breakdown from misconduct and willful negligence.
TERCAP: CASE STUDY ANALYSES
Initially, the PBAP analyzed 26 cases related to issues of discipline obtained from various jurisdictions to discover characteristics of nurses at risk for making errors and to learn more about practice breakdown. Ultimately, the expert panel examined 109 cases.
In the initial analyses, the PBAP examined documents that included original discipline complaints, investigative reports, additional relevant documentation, and public documents related to a case. When available, the analysis included the nurse’s story in his or her own handwriting and/or transcripts of the nurse’s interactions with the regulatory agency. Nurse and patient names were redacted from all materials prior to submission for analysis.
DESCRIPTION OF TERCAP
TERCAP is divided into 10 sections. The first section asks for information about the setting in which the practice breakdown occurred. This is to facilitate identification of multiple sources for error prevention. It also asks about the nurse’s education, licensure, and work history.
Next, users are directed to identify in the next section the contributing elements of error. Investigators are invited to analyze the events of the case and determine the causes for practice breakdown. They select the primary cause of the breakdown from the taxonomy categories based on the category of breakdown they perceive as most proximal to causing the patient direct harm.
Data are also collected on other factors that may contribute to a discipline case. These include relevant practice and systems contributions to practice breakdown, outcomes for the involved patients, and outcomes related to the individual nurse. Finally, the investigators evaluate the outcomes of the case from the perspective of the patient and from the nurse.
VALIDITY
The PBAP used the data from the initial analysis to create and strengthen TERCAP for validity and reliability. They served as content experts as they examined early versions of TERCAP to track case elements and recurring themes, analysis of root cause, practitioner and health care team contributions, and practice responsibility. Subsequently they reviewed additional cases prior to finalizing the data collection instrument. Following these analyses, 16 boards of nursing submitted 109 cases using TERCAP. The PBAP’s analysis identified problem areas and revised the data collection instrument based on these findings. In addition to these reviews, the president of the American Nurses Association (ANA) and a member of The Joint Commission reviewed the text and emphasized the need for a preventive rather than punitive focus.
The challenges of creating conceptual clarity for the eight categories of practice breakdown continually challenged the PBAP members. Definitions and clear descriptions of safe medication administration, documentation, prevention, and interventions emerged with little difficulty. The categories of attentiveness/surveillance, clinical reasoning, interpretation of provider orders, and professional advocacy/patient advocacy required much more discussion and clarification. Initially, the clinical reasoning category was labeled clinical judgment. This label proved to be too generic in that nursing practice requires clinical judgment in all patient care encounters. The term “clinical reasoning” was adopted to capture reasoning across time about changes in the patient’s clinical condition and changes in the clinician’s understanding of the patient’s clinical condition (Benner, Hooper-Kyriakidis, & Stannard, 1999). Inherent to the narrower view of clinical reasoning is the adjustment of therapies administered by nurses according to the patient’s responses so that a desirable therapeutic effect is achieved over time. Members further clarified the categories on a continuum basis. Attentiveness necessarily precedes clinical judgment. Once clinical judgment occurs, the next step is to intervene or provide care. Prevention follows clinical judgment since the nurse must determine the need for prevention prior to implementing preventive measures. Conceptual clarity about the aims and usual sequence of these eight practice breakdown categories improved inter-rater reliability among those using the TERCAP instrument.
The preparation of board investigators became an issue during the analysis of the cases. Although TERCAP was created from the perspective of nursing knowledge, many of the investigators at boards of nursing do not have nursing backgrounds. In light of this possible source of variance, the PBAP conducted additional revisions to ensure clarity for a broader group of investigators. Also the TERCAP code book was enriched with examples and operational definitions to guide the investigators’ use of the TERCAP instrument.
RELIABILITY
Reliability is the extent to which different coders, each coding the same content, come to the same coding decisions. Data collection that relies on humans to obtain measurements involves estimates of agreement known as inter-rater reliability. Inter-rater reliability is used when opinions and interpretation of facts are required of multiple raters evaluating or interpreting the same behavior or information.
The need to establish inter-rater reliability is important for instruments such as TERCAP that are developed to evaluate the reasons practice breakdown occurs in the delivery of quality health care to patients. The TERCAP instrument requires the investigator to make a judgment about the patient’s care and the nurse’s behavior based on interviews and a review of records. The coder fills in the TERCAP instrument based on the facts of the case and on the investigator’s interpretation of the event.
Many potential sources of measurement error may occur during this process. Inconsistency among raters regarding correct values or conclusions, bias, and idiosyncratic use of the instrument affects the reliability of the information provided. Establishing the degree of inter-rater reliability of a data collection instrument is a necessary condition before validity can be ascribed to the obtained set of ratings. If two or more coders cannot be shown to rate reliably, then any subsequent analyses of their ratings will yield false results.
To assess coder inter-rater reliability, several members of the expert panel created a hypothetical case study based on real cases and asked coders to complete TERCAP for the same case. Thirty-four people from boards of nursing, the NCSBN, and Practice Breakdown Advisory Panel (PBAP) read the case and completed TERCAP. Coders did not receive additional training on the latest version of the instrument’s classification scheme nor were they instructed in filling it out. They were provided with examples and definitions to clarify each question.
Two methods are commonly used to establish rater agreement: percent agreement and Cohen’s chance-corrected kappa statistic (Cohen, 1960). In general, percent agreement is the ratio of the number of times two raters agree divided by the total number of ratings performed. The kappa statistic estimates the proportion of agreement among raters after removing the proportion of agreement that would occur by chance. If the raters are in complete agreement, kappa equals 1. If there is no agreement among the raters (other than what would be expected by chance), kappa is less than or equal to 0.
To compute kappa, the PBAP first identified the “correct” answer for each question. Agreement was then computed based on the number of coders who agreed with the “correct” answer. Each coder read the case and supplied the information requested (e.g., age) or selected responses from predefined categories. TERCAP includes 60 questions; however, for each question where the coder was requested to check “all that apply,” each answer category was treated as a separate question. Thus, for analysis purposes, 154 items were used in the final analysis. Kappa was computed as follows: κ=PA–PC1–PC where:
PA = proportion of units on which the raters agreed with the experts’ designated correct answer.
PC = the proportion of units for which agreement with the correct answer is expected by chance (1 ÷ number of response categories).
As an illustration, if 32 out of the 34 coders selected the “correct” answer for a particular question, the proportion of units on which the raters agreed with the experts’ designated correct answer (PA) would equal 0.94. If there were 13 possible response categories, the proportion of units for which agreement with the correct answer is expected by chance would equal 0.76. The kappa for that question is, therefore, 0.936.
The kappas for each question were added and divided by the number of questions to derive the mean or overall kappa for the TERCAP instrument. The kappas for each section of TERCAP were computed in the same manner. Section 1: Patient Profile, for example, included 16 questions. A kappa was computed for each of the 16 questions in that section. The mean of the 16 kappas represented the kappa for that section.
The desired level of inter-rater reliability that must be achieved for any given study has not been established clearly. Researchers generally think that values greater than 0.75 or above may be taken to represent excellent agreement beyond chance, values below 0.40 may be taken to represent poor agreement beyond chance, and values between 0.40 and 0.75 are considered to represent fair to good agreement beyond chance (Capozzoli, McSweeney, & Sinha, 1999).
TABLE 1.5 Overall and Section Inter-Rater Reliability of TERCAP by Coefficients of Agreement

Sections by Title Kappa
1. Patient Profile 0.80
2. Patient Outcome 0.67
3. Setting 0.78
4. Systems Issues 0.67
5. Health Care Team 0.70
6. Nurse Profile 0.78
7. Intentional Misconduct or Criminal Behavior 0.57
8. Safe Medication Administration 0.89
9. Documentation 0.74
10. Practice Breakdown Other Categories 0.68
Overall 0.75

It is expected that the assessment of TERCAP will improve as groups make refinements to the instrument. As of the publication of this book, the coders, on average, agreed with the experts 97% of the time, and the overall inter-rater reliability achieved was 0.75 indicating excellent agreement between coders. The coefficients of agreement for each of the sections of TERCAP are shown in Table 1.5.
UTILITY
TERCAP is easy to administer. The electronic application is user friendly and includes links to the TERCAP coding protocol. Users in the pilot submitted TERCAPs based on discipline cases that had been completed in 2004 forward. The instructions required users to review the entire case file retrospectively, a process that can consume considerable time. The time to complete TERCAP took users between 20 minutes and 3 hours. The time factor was influenced by the familiarity of the user with the case and the ready availability of data. In future applications, investigators are likely to collect the information as a case progresses (e.g., using the instrument as an intake document that is attached to the case file). Once the case is resolved, the completed data will be entered into the electronic TERCAP for transmission to the NCSBN where the document will be stored for filing, retrieval, and analysis.
USING TERCAP—BOARDS OF NURSING
Boards of nursing are beginning to identify a variety of uses for TERCAP. TERCAP provides a consistent language to describe practice breakdown for board of nursing investigators, staff, and attorneys, and it guides the consistent and comprehensive collection of data. The categories of error and subcategories are being used to develop checklists for investigators to assist in data collection. TERCAP also provides a framework for case analysis that supports boards in their decision-making processes. Specific examples of the use of TERCAP by the North Dakota and Ohio Boards of Nursing are described in Implications and Applications for State Boards of Nursing, which can be found on the NCSBN’s website at www.NCSBN.org.
PROCEDURES
ACCESS TO CASES
Members of the PBAP identified cases from their respective states that were completed within the last 60 months. They removed personal data from the cases prior to inclusion in the documents prepared for discussion and analysis.
DATA MANAGEMENT
Response categories created by the coders were identified as “not applicable,” assigned a code (e.g., 999), and entered into the database when the response was not among a question’s original response category. Invalid character values and invalid data that were either below or above expected ranges were transcribed exactly as they were written on the form. The only data that were modified were the dates transformed into their proper format of dd/mm/yyyy. The original hard copy data were retained to facilitate return to the original information. The NCSBN filed and stored the data for future retrieval.
DATA ANALYSIS
TO IMPROVE THE QUALITY OF THE DATA
The staff at NCSBN worked to improve the quality of data through several processes. To do this, they analyzed the differences between the given response categories, and they also analyzed respondents’ answers. For example, a number of coders added categories such as “unknown” to some questions. These categories, if deemed necessary, were added to subsequent versions of the questionnaire.
TO ESTABLISH INTER-RATER RELIABILITY
As noted, inter-rater agreement and the kappa statistic were used to establish inter-rater reliability. The PBAP then reviewed prepared tables of the results by section and for the entire instrument.
The items on TERCAP will allow for descriptive statistics on the types of nursing practice breakdown that represent the major contributions to nursing practice breakdown at the state and national levels. The following correlation studies could be useful in understanding system, patient, and nurse characteristics associated with different levels of patient harm:

  • 1Correlation between the type of nursing practice breakdown and level of patient harm
  • 2Correlation between patient characteristics and types of practice breakdown and patient harm
  • 3Correlation between system sources of practice breakdown and types of practice breakdown
  • 4Correlation between nurse education and working patterns and type of practice breakdown

The electronic database will also provide an ongoing basis for assessing interventions at the state and national levels. In addition, the intake instrument (TERCAP) is sufficiently comprehensive to provide unanticipated data for analyzing specific types of practice breakdown prevalent in different types of health care institutions.
NCSBN will analyze and publish national data only. Individual state data will be published only with the expressed and written permission of the state board(s) of nursing. Individual states will be able to manage and analyze their data based on their needs. The findings from analysis of these data will provide evidence that has not been previously available to objectively advance the patient safety movement from the perspective of safe nursing practice. State boards of nursing will have the opportunity to conduct studies to determine whether specific state board educational interventions reduce certain classes of errors for nurses who have been reported. The collection of valid and reliable data and ongoing evaluation will continually reinforce and guide decision-making and strategy development.
SUMMARY
This practice breakdown research effort describes and classifies the characteristics of various nursing errors. The overall aim of the PBAP is far reaching. It is to promote patient safety by better understanding nursing practice breakdown and by improving the effectiveness of nursing regulation. The ultimate goal is to develop an interpretive guide for statistically analyzing data and writing a report that will include recommendations for nursing education and practice settings to reduce and prevent practice breakdown based on the actual reported incidents in each state.
These reports are expected to facilitate communication concerning the types of nursing errors and efforts at error prevention across states. Ultimately, the expectation is to transform a valuable, untapped, and unaggregated data set regarding actual errors into useful interpreted data that can provide concrete suggestions for reducing and preventing breakdown through education, system redesign, and enhanced individual and professional practice responsibility. These expectations are in keeping with the key principles that inform the work of boards of nursing in the United States and provide the needed evidence for a major change in the way nursing practice breakdown is viewed, understood, prevented, or decreased.
The adoption of a Web-based data collection instrument will advance the work of practice breakdown analysis. Data from TERCAP will be collected in the NCSBN national data center to allow for examination of the relationships between and among nurse demographics regarding category(s) of breakdown and system variables. The variability of patterns of errors can be compared between states and between types of systems, nurse characteristics, patient characteristics, working conditions, and system characteristics. Relationships between variables will be analyzed to identify new and more focused approaches to safe nursing practice.
The findings from analysis of these data will provide evidence that has not been previously available to objectively advance the patient safety movement from the perspective of safe nursing practice. State boards of nursing will have the opportunity to conduct studies to determine whether specific state board educational interventions reduce certain classes of errors for nurses who have been reported. The collection of valid and reliable data and ongoing evaluation will continually reinforce and guide decision-making that is reflective of clear problem identification, development of plans to address the problem, judgment of the feasibility of the plan, guidance regarding the implementation of the plan, and then provision of evidence from evaluation as a basis for any needed future revisions (rather than best guess decision-making). More information specific to the nature, scope, and causes of safety breaches will be identified using TERCAP.
We believe that this instrument and taxonomy of nursing practice can also be used by individual nurses in thinking about practice breakdown in their practices. It is also useful as an “upstream” data collection instrument in all health care delivery sites.
References
In P. Aspden, J.M. Corrigan, J. Wolcott, S.M. Erickson (Eds.): Committee on Data Standards for Patient Safety; Institute of MedicinePatient safety: Achieving a new standard for care. 2004, The National Academies Press, Washington, DC.
In P. Aspden, J. Wolcott, L. Bootman, L. Cronenwett (Eds.): Committee on Identifying and Preventing Medication Errors, Institute of MedicinePreventing medication errors. 2006, The National Academies Press, Washington, DC.
P. Benner, P. Hooper-Kyriakidis, D. Stannard: In Clinical wisdom and interventions in critical care: Thinking-in-action approach. 1999, Saunders, Philadelphia.
P. Benner, V. Sheets, P. Uris, K. Malloch, K. Schwed, D. Jamison: Individual, practice, and system causes of errors in nursing: A taxonomy. Journal of Nursing Administration32(10), 2002, 509–523.
P. Benner, V. Sheets, P. Uris, K. Malloch, K. Schwed, D. Jamison, et al.: TERCAP: Creating a national database on nursing errors. Harvard Health Policy Review7(1), 2006, 48–63.
Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (In press.) Educating nurses: A call for radical transformation. San Francisco: Jossey-Bass and Carnegie Foundation for the Advancement of Teaching.
M. Capozzoli, L. McSweeney, D. Sinha: Beyond kappa: A review of inter-rater agreement measures. The Canadian Journal of Statistics27(1), 1999, 3–23.
J. Cohen: A coefficient of agreement for nominal scales. Educational and Psychological Measurement20, 1960, 37–46.
Committee on the Quality of Health Care in America, Institute of Medicine: In Crossing the quality chasm: A new health system for the 21st century. 2001, The National Academies Press, Washington, DC.
J.B. Cooper, D.M. Gaba, B. Liang, D. Woods, L.N. Blum: The National Patient Safety Foundation Agenda for Research and Development in Patient Safety. Medscape General Medicine2(3), 2000, E38.
L. Cronenwett, G. Sherwood, J. Barnsteiner, J. Disch, J. Johnson, P. Mitchell, et al.: Quality and safety education for nurses. Nursing Outlook55(3), 2007, 122–131.
A. Gawande: Annals of Medicine: The Checklist. If something so simple can transform intensive care, what else can it do?. In The New Yorker. 2007, December 10, 2007.
In A.C. Greiner, E. Knebel (Eds.): Committee on the Health Professions Education Summit, Institute of MedicineHealth professions education: A bridge to quality. 2003, The National Academies Press, Washington, DC.
In L.T. Kohn, J.M. Corrigan, M.S. Donaldson (Eds.): Committee on Quality of Health Care in America, Institute of MedicineTo err is human: Building a safer health system. 2000, The National Academies Press, Washington, DC.
L.L. Leape, A.G. Lawthers, T.A. Brennan, W.G. Johnson: Preventing medical injury. Quality Review Bulletin19(5), 1993, 144–149.
B.A. Liang: Addressing the nursing work environment to promote nursing safety. Nursing Forum42(1), 2006, 20–30.
A. MacIntyre: In After virtue: A study in moral theory. 2nd ed., 1984, University of Notre Dame Press, Indianapolis.
D. Marx: In Patient safety and the “just culture”: A primer for health care executives. 2001, Columbia University Press, New York.
National Patient Safety Foundation: In Focus on patient safety. 1999, Available online at www.npsf.org, Retrieved November 17, 2008.
In A. Page (Ed.): Committee on the Work Environment for Nurses and Patient Safety, Institute of MedicineKeeping patients safe: Transforming the work environment of nurses. 2004, The National Academies Press, Washington, DC.
B.B. Pope, L. Rodzen, G. Spross: Raising the SBAR: How better communication improves patient outcomes. Nursing38(3), 2008, 41–43.
J. Reason: In Human error. 1990, Cambridge University Press, Cambridge.
J. Reason: In Managing the risks of organizational accidents. 1997, Ashgate Publications, Burlington, VT.
P.W. Stone, C. Mooney-Kane, E.L. Larson, T. Horan, L.G. Glance, J. Zwanziger, et al.: Nurse working conditions and patient safety outcomes. Medical Care45(6), 2007, 571–578.
W. Sullivan: In Work and integrity: The crisis and promise of professionalism in America. 2nd ed., 2004, Jossey-Bass, San Francisco.
W. Sullivan: Challenges to professionalism: Work integrity and the call to renew and strengthen the social contract of the professions. American Journal of Critical Care14(1), 2005, 78–80, 84.
C. Vincent: Understanding and responding to adverse events. New England Journal of Medicine348(11), 2003, 1051–1056.
C. Vincent, S. Taylor-Adams, N. Stanhope: Framework for analysing risk and safety in clinical medicine. BMJ316(7138), 1998, 1154–1157.
R.M. Wachter: In Understanding patient safety. 2008, McGraw Hill Medical, New York.
R.M. Wachter, K.G. Shojania: In Internal bleeding: The truth behind America’s terrifying epidemic of medical mistakes. 2004, Rugged Land, New York.
K.E. Weick, K.M. Sutcliff: In Managing the unexpected: Assuring high performance in an age of complexity. 2001, Jossey-Bass, San Francisco.
P.J. Woods: In Integrating evidence-based nursing practice into education, research and patient care. Paper presented at the 2004 Quality Colloquium 2004, Harvard University, Cambridge, MA.
A.W. Wu: Medical error: The second victim. Western Journal of Medicine172(6), 2000, 358–359.
A.W. Wu, S. Folkman, S.J. McPhee, B. Lo: Do house officers learn from their mistakes?. Journal of the American Medical Association265(16), 1991, 2089–2094.