2007 NCSBN IRE Fellowship Project

2007 NCSBN IRE Fellowship Project

Kathy Chastain, RN, MN, Practice Mgr.Julie George, RN, MSN, FRE, Associate Executive Director

ProblemProblem

Board resources may be spent needlessly on matters that do not violate nursing law

Employers and Boards have few tools to guide their analysis of events

BackgroundBackground

NC is a mandatory reporting state Existing culture of “blame” for error Need to distinguish error from

intentional misconduct NCBON strategic initiative to move

toward “Just Culture”

“Just Culture”“Just Culture”

Focus on behavioral choice, not outcome

Levels of risk Systems design Categories of: human error, at-risk

behavior, and reckless behavior

Multi-Year ProjectMulti-Year Project

Year 1: Development of reporting tool to guide employers and Board staff in review of incidents

Tool to be aligned with Just Culture philosophy and existing algorithm

Year 1Year 1

Work with David Marx on implementing Just Culture in NC

Collaboration with others Literature review Review of state regulations Design of tool

Criteria

Human Error At Risk Behaviors Reckless Behaviors Score

0 Points 1 Point 2 Points 3 Points 4 Points 5 Points

Awareness Meant to do one thing but did another - accidental

Considered negligible risk to patient/benefit to patient/nurse

Considered minimal to moderate risk for patient/benefit to patient outweighed risk/emergent situation

Considered moderate to high risk for patient/failed to utilize resources/non-emergent situation

Considered moderate to high risk for patient/clearly a prudent nurse would not have done/risk to patient outweight beneift

Considered high risk for patient/benefit to nurse evident/no regard for patient safety

Policy/System

No policy/procedureUnintentional breech (accidental)Systems design flaw (others likely to make same error)

Common practice of staff (cultural norm) – practice slightly different than policy/procedure (bending of rules)

Individual practice slightly different than policy/procedure - no evidence of cultural norm (bending of rules)

Failed to check policy/procedure or utilize resources prior to performing unfamiliar task

Individual knowingly disregarded policy/procedure or bypassed system to achieve perceived expectations of management, patient or others

Individual knowingly disregarded policy/procedure or bypassed system for own personal gain

Competency Accidental event regardless of level of competency

Advanced beginner, needs supervision, understands procedure but may not understand theory

Competent in performing task/procedure correctly, used minor discretion in carrying out work, aware of safety issues but in this incident cut corners

Proficient in performing task/procedure correctly, understands rationale of correct action yet regularly deviates from standards

Proficient in performing task/procedure, is in a position to negatively influence others by action

Incompetent, Individual knowingly accepted assignment to perform task/procedure without possessing the necessary knowledge/skills/ability and did not seek assistance

Repetitive No prior counseling for practice issues

Prior counseling for single non-related practice issue within last year

Prior counseling for single related issue within last year

Prior counseling for same issue within last year

Prior counselings for various practice issues within the last year with some attempts at remediation

Prior counseling for same or related issue within the last six months. No or limited evidence that remedial steps were taken by nurse to improve own practice

Credibility Identified own error and self reported

Readily admitted error when made aware and accepts responsibility for own action

Acknowledged role in error but attributes to circumstances and/or blames others to justify actions

Continued to deny responsibility until confronted with evidence

Denied any responsibility despite evidence presented

Evidence demonstrates individual took active steps to cover up error or failed to disclose known error

Options for event review:Options for event review:

Consultation only Employer directed corrective action Formal corrective action Formal reporting

Year 2Year 2

Evaluate tool through pilot project

Participating pilot hospitals must have had formal Just Culture training

Pilot ProjectPilot Project

Hospitals use complaint evaluation tool to determine whether Board should be contacted for practice incidents

Differentiate incidents resulting from human error from those resulting from at-risk and reckless behaviors

ScenariosScenarios

Desired Outcomes Desired Outcomes

Common framework for review or practice events that lends itself to continuous quality improvement

Balance individual and system accountability

Consistency in how practice breakdown is reported and addressed

ContactsContacts

Contacts: Telephone: (919) 782-3211 Kathy Chastain, RN, MN

KathyC@ncbon.com ext 227

Linda Burhans, RN, PhD(c)

Lburhans@ncbon.com ext 265

Julie George, RN, MSN, FRE

Julie@ncbon.com ext 276