Learning From Nursing Mistakes

July 18th, 2012

By Jennifer Olin, BSN, RN

Sometimes nurses make mistakes. We are human. The most important thing about mistakes is that you can learn from them. With that in mind the National Council of State Boards of Nursing (NCSBN) developed TERCAP.

The Taxonomy of Error, Root Cause Analysis and Practice-responsibility (TERCAP) was designed as an intake instrument for collecting data from participating state nursing boards' discipline cases. The information gleaned from theses cases is used to identify areas of nursing error.

Identifying these errors through the TERCAP Adverse Event Reporting System allows us to learn from incidents involving the breakdown in nursing practice and provide a method to evaluate multiple factors that may be involved in those practice errors. With this information nursing can work on safeguards and other means of preventing those same mistakes in the future.

History of TERCAP

In 1999, the NCSBN Board of Directors appointed a task force to develop new knowledge about the causes of nursing practice breakdown. Up until that time most patient safety research had focused on medical errors.

With over three million nurses in the United States, nurses comprise the largest group of health care providers in this country. This also means that nurses have the most interaction with patients. Identifying, analyzing, and tracking practice breakdown can identify generic patterns in error, risk factors, and system contributions. Identifying these assists in developing new approaches to prevent further breakdown.

In 2004, the following recommendation was made in the Third Institute of Medicine report on patient safety entitled, “Keeping Patients Safe, Transforming the Work Environments of Nurses:”

“Recommendation 7.2: The National Council of State Boards of Nursing [NCSBN], in consultation with patient safety experts and health care leaders, should undertake an initiative to design uniform processes across states for better distinguishing human errors from willful negligence and intentional misconduct, along with guidelines for their applicability by state boards of nursing and other state regulatory bodies (IOM, 2004, p. 15).”

Of course by the time this report reached the public eye the NCSBN project had been underway for five years. As part of the TERCAP development, the following practice categories were chosen to identify areas to be studied for good nursing practice. Member boards will identify practice breakdown in:

1. Safe Medication Administration – The nurse administers the right dose of the right medicine via the right route to the right patient at the right time for the right reason.
2. Documentation – The nurse ensures complete, accurate, and timely documentation.
3. 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 the patient, then the nurses cannot identify changes if they occurred and/or make knowledgeable discernments and decisions about the patient.

4. Clinical Reasoning – The nurse interprets patient signs, symptoms, and responses to therapies. The nurse evaluates the relevance of changes in patient signs and symptoms and ensures that patient care providers are notified and that patient care is adjusted appropriately.

   The nurse titrates drugs and other therapies according to their assessment of patient responses (e. g. assesses patient’s pain and adjusts pain medications).

5. 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, etc.
6. Intervention – The nurse properly executes healthcare procedures aimed at specific therapeutic goals.

   Interventions are implemented in a timely manner.

   The nurse performs the right intervention on the right patient.

7. Interpretation of Authorized Provider’s Orders – The nurse interprets authorized providers orders.
8. 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/concerns are addressed.

The TERCAP project is voluntary and although the NCSBN invites all of its member boards of nursing to participate, as of October 2011, only 23 BONs submit cases to the NCSBN TERCAP database.

Based on 861 TERCAP cases, NCSBN conducted the first round of analysis and found the following:

• Overall, 72 percent of the cases were unintentional human errors. Among the nurses who were reported to BONs for committing practice breakdown, 60 percent were registered nurses (RNs), 37 percent were licensed practical/vocational nurses (LPNs/VNs), one percent were advanced practice registered nurses (APRNs) and three percent held either RN and LPN/VN or RN and APRN licenses.
• There is a significant association between the nurses’ employment history (discipline and termination by employers) and practice breakdown. Among the 725 nurses with complete employment history (previous discipline and termination by their employers), 60 percent had been disciplined and/or terminated by their employer(s) previously.
• Furthermore, the data indicated that 55 percent of practice breakdowns occurred when a nurse worked in a patient care position for two years or less, but 73 percent of these nurses had been licensed for two years or longer.
• The current data did not reveal sufficient association between system factors and any types of practice breakdown.

The TERCAP is still in its early stages of usage but this instrument shows potential for use in many areas of nursing. For example, state BONs can compare their patterns of error with those of other states. This could then help the individual states determine if specific educational interventions can reduce certain classes of errors. Those educational interventions could then be added as mandatory state licensing continuing education requirements.

TERCAP reports could also be used by schools of nursing in designing educational programs and curricula to better prepare nursing students for safer patient care environments and standards.

Learning from our mistakes. That really is the basis of TERCAP. We analyze what happened, we look at where the breakdown started and we address the issue at hand. TERCAP provides the information to do just that. You can find out if you state participates in TERCAP by contacting your own state board of nursing.