A Study to Identify Evidence-Based Strategies for the Prevention of Nursing Errors

A Study to Identify
Evidence-Based Strategies for
the Prevention of Nursing Errors




Prepared by
Board of Registration in Nursing
Division of Health Professions Licensure
Massachusetts Department of Public Health





December 2007

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COMMONWEALTH OF MASSACHUSETTS


Board of Registration in Nursing

Diane M. Hanley, MS, RN
Chair

Rula Harb, MS, RN
Executive Director

Carol A. Silveira, MS, RN
Assistant Director and Principal Investigator

Maura Flynn, LPN, RN
Donna L. Lampman, MSN, RN
Paulette Remijan, MS, RN, NP
Janet Sweeney Rico, MS, RN, NP, Vice-Chair
Mary Jean Roy, MS, MEd, RN
David Seaver, RPh, J.D.
Philip E. Waithe, RN
Board Members



Division of Health Professions Licensure

Jean K. Pontikas, Director



Department of Public Health

John Auerbach, Commissioner




Special Thanks
R. Gino Chisari, MS, RN
Amy Fein, JD, BSN, RN
Bette Lindberg, MS, RN
Sean Erickson

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Table of Contents



Executive Summary
1. Introduction.................................................................................................................. 1
2. Background ................................................................................................................. 2
3. Methodology................................................................................................................ 4
4. Results ........................................................................................................................ 6
5. Study Limitations ....................................................................................................... 21
6. Discussion ................................................................................................................. 22
7. Conclusions and Recommendations ......................................................................... 28

Appendix 1: CY 2005 Closed Complaint Cases: Frequency of Allegation and
Case Decision .......................................................................................... 31
Appendix 2: Taxonomy.................................................................................................. 33
Appendix 3: Description of Nursing Error Categories .................................................... 43
Appendix 4A: Violations of the Five Rights of Medication Administration:
Medication Administered to the Wrong Patient ....................................... 44
Appendix 4B: Violations of the Five Rights of Medication Administration:
Wrong Drug Administered to Patient ....................................................... 46
Appendix 4C: Violations of the Five Rights of Medication Administration:
Wrong Dose Administered to Patient ...................................................... 48
Appendix 4D: Violations of the Five Rights of Medication Administration:
Drug Administered by the Wrong Route .................................................. 51
Appendix 5: Board Actions by Type of Nursing Error .................................................... 52

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Executive Summary

Context: The Fiscal Year 2005 Budget required the Massachusetts Board of Registration in
Nursing (Board) to prepare a compilation of complaint cases involving preventable medical errors
that were associated with harm to a patient or health care provider for the purpose of assisting
health care providers, hospitals and pharmacies to modify their practices and techniques to avoid
error.

Design, Setting, and Participants: This descriptive study was designed to examine the
incidence and nature of nursing errors among 34 RNs and 44 LPNs selected from the 661
complaint cases closed by the Board between January 1, 2005, and December 31, 2005. This
sample was chosen by applying a three-tiered selection process in which 97 complaint cases
involving 52 RNs and 45 LPNs were initially identified. On review of the practice setting present in
each of the 97 complaint cases, it was noted that 78 of the cases involved both RNs and LPNs
practicing in nursing homes. Of the remaining 19 complaint cases, 18 involved RNs who practiced
in a variety of institutional and community-based settings and only one LPN who practiced in a
physician’s office. Although the resulting sample was small, a decision was made to focus data
analysis on the 78 nursing home-based cases since they represented 80% of the 97 complaint
cases meeting the initial three-tier selection criteria and included both RN and LPNs. The 78
nursing home-based cases represented 12% of the 661 complaint cases closed by the Board in
Calendar Year (CY) 2005. Using a case analysis format, data was collected using a modified
Taxonomy of Error, Root Cause Analysis and Practice Responsibility (TERCAP™) audit
instrument1. For the purpose of this study, a nursing error was defined as the failure of a planned
nursing action to be completed as intended or use of a wrong nursing plan to achieve an aim
(adapted from the Institute of Medicine’s 1999 To Err Is Human, Building a Safer Health System
definition of “error”2).

Objectives: This study was designed to 1) Describe the characteristics of the nurse, patient and
practice setting involved in the complaint case; 2) Categorize the nursing error and harm outcome;
3) Examine possible causative or contributive factors at two levels: the nurse and the practice
environment; 4) Identify actions taken by the Board and the nurse’s employer in response to the
nursing error; and 5) Recommend evidence-based strategies to reduce or prevent the occurrence
of nursing errors.

Results: In this study of 78 complaint cases involving 34 RNs and 44 LPNs, seven nursing error
categories were identified in the care of 62 primarily female patients who were residents of 50
nursing homes (average: 131 beds; median: 125 beds) located in Massachusetts. The nurses were
primarily female (91%), 44 years of age, graduates of US nursing programs and involved in a
single incident nursing error (90%). At the time the nursing error occurred, RNs had been licensed
an average of 15 years (median: 9.75 years) while LPNs were known to have been licensed for an
average of 11 years (median: 8 years). Seven of the 44 LPNs were licensed for 12 months or less
(average was 6 months); none of the RNs had been licensed for 12 months or less. Twenty-two
(65%) RNs received their basic nursing education at the Associate Degree level. Seventy (90%) of
the 78 nurses were known to hold direct care positions; job tenure averaged 3.6 years. Seventeen
(22%) of the 78 nurses were employed by temporary staffing agencies. Nursing errors occurred
most often between 5:00 p.m. and 6:30 p.m. followed by 5:00 a.m. and 6:30 a.m. Most nurses
were assigned to work an eight-hour shift from 3 p.m. to 11 p.m. when the nursing error occurred.

1 National Council of State Boards of Nursing. (2005). Taxonomy of Error, Root Cause Analysis and Practice
Responsibility (Version 02182005). Chicago, IL: Author. Used with the permission.
2 Kohn, L., Corrigan, J., & Donaldson, M. (Eds). (1999). To err is human: Building a safer health system.
Washington, DC: National Academy Press. Retrieved July 5, 2006 from the World Wide Web:
http://fermat.nap.edu/openbook.php?record_id=9728&page=210.

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Nursing errors by 46 (59%) of the 78 nurses were associated with harm to 37 patients including
nine deaths. None of the nursing errors were associated with harm to the nurse. Stress and a
“high volume of work”; inexperience with particular clinical events, procedures or conditions; and a
lack of familiarity with the practice setting were cited most often by the nurses as contributing to the
nursing error.

Errors in medication administration were the most common error category overall as well as among
the seven novice LPNs and the 17 nurses employed by temporary staffing agencies. 50% of the
medication administration errors were associated with harm to 15 patients including one death.
The majority of medication administration errors were associated with the nurse’s violation of one
or more of the “five rights and three checks” of medication administration (administration of
medication to the wrong patient because the nurse failed to verify the patient’s identity was the
most common violation). Practice environment or “system” factors associated with medication
administration errors included frequent interruptions during the medication administration process
and the lack of policies requiring “independent double checks” and “read backs”. Medication
administration errors among the novice LPNs were also associated with the lack of consistently
assigned preceptors and the adequacy of the novice nurses’ transition program.

Errors in clinical judgment were the second most common error category and were associated with
harm to12 patients including six known deaths. Clinical judgment errors were associated most
frequently with the nurse’s knowledge deficit, the nurse’s failure to recognize or correctly interpret
the implication of the patient’s signs and symptoms and the nurse’s failure to provide adequate
patient monitoring. The health care team’s lack of awareness of the patient’s goals, information
missing from patient records and communication breakdown including at change-of-shift hand-offs
were the most common practice environment-related factors associated with clinical judgment
errors.

Overall, the Board imposed 27 remedial sanctions in the interest of public safety; all nurses
retained their license to practice. The Board dismissed the remaining 51 complaint cases following
its consideration of substantiating evidence.

Conclusions and Recommendations:
Nursing competence and the infrastructure of the nurse’s practice environment have implications
for safe nursing practice and the prevention of nursing errors. In addition, this study indicates that
while the Board may be perceived by some nurses as punitive, its actions following its investigation
and evaluation of nursing complaints do not bear this out. Evidence-based error-prevention
strategies focused on medication administration, heat therapy, resuscitation directives and
standardized hand-off communications for use by individual nurses, educators, employers and
regulators are recommended. Examples include collaborative efforts among nurses, employers,
professional associations, risk management and regulatory agencies to advance quality
improvement and the collection and dissemination of data, and the creation of non-punitive
practice environments that support voluntary error reporting; active participation by individual
nurses in interdisciplinary root cause analyses; systematic reviews of clinical standards; conducting
practice audits; and the issuance of patient safety alerts.

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1. Introduction

The Massachusetts Board of Registration in Nursing (Board) is created and authorized at
General Laws (G.L) chapter 13, sections 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74
through 81C to protect the health, safety and welfare of the citizens of the Commonwealth
through the regulation of nursing practice and education. Members of the Board are committed
to consumer access to safe patient care that is provided by qualified Licensed Practical Nurses
(LPNs), Registered Nurses (RNs), and Advance Practice Registered Nurses (APRNs) including
Nurse Anesthetists, Nurse Midwives, Nurse Practitioners and Psychiatric Nurse Mental Health
Clinical Specialists.

In August 2005, the Board approved its three-year strategic vision, mission and goals.
Assuming a leadership role in patient safety, and regulatory innovation and outreach are among
its primary initiatives. Some of the activities that support the achievement of these initiatives
include the Board’s active collaboration with other regulatory agencies and private
health care-related organizations to advance quality improvement, and the collection and
dissemination of data to facilitate the development and implementation of evidence-based
patient safety programs.

Consistent with the Board’s strategic initiatives, Chapter 149, section 2 of the Acts of 2004
(Fiscal Year 2005 Budget) requires the Board to “prepare a compilation of complaint cases
involving preventable medical errors that were associated with harm to a patient or health care
provider for the purpose of assisting health care providers, hospitals and pharmacies to modify
their practices and techniques to avoid error.” In response, this report provides an analysis of
selected complaint cases that involved a nursing error where actual or potential harm resulted to
the patient or nurse and that were closed by the Board between January 1, 2005, and
December 31, 2005, in order to:

• Describe the characteristics of the nurse, patient and practice setting;
• Categorize
the
nursing error and harm outcome;
• Examine possible causative or contributive factors at two levels: the nurse and practice
environment;
• Identify actions taken by the Board and the nurse’s employer in response to the nursing
error; and
• Recommend evidence-based strategies for use by individual nurses, nurse educators and
employers, and regulatory agencies to reduce or prevent the occurrence of nursing errors.
A Study To Identify Evidence-Based Strategies For the Prevention of Nursing Errors - 2007
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2. Background

A.Massachusetts Board of Registration in Nursing
Created by statute in 1910, the Board’s current composition is established by G.L. c. 13, § 13 to
include nine RNs (including two APRNs), four LPNs, a licensed physician, a licensed
pharmacist, and two consumers. By statute, each nurse member is required to possess at least
eight years of nursing experience. Section 13 also specifies that the Board’s RN and LPN
members represent practice in acute care, long-term care and community health settings and
further designates nurse representation by:
• direct patient care providers;
• nurse educators from each level of education whose graduates are eligible for RN and LPN
licensure by examination (baccalaureate and higher degree entry-level programs are
considered one level); and
• one nursing service administrator responsible for service-wide policy development and
implementation.

Throughout Calendar Year 2005, the Board was comprised of12 appointed members including
eight of the nine RNs (including 2 APRNs), two of the four LPNs, a licensed pharmacist and a
consumer. Of the appointed RNs and LPNs, there were direct care providers and nurse
educators from Practical Nurse, Hospital-based RN, Associate Degree (RN), and Baccalaureate
Degree (RN) education. In addition, a representative of nursing service administration held a
Board appointment through May 2005. A second consumer representative also served through
August 2005. Appointments to the following seats were not filled during Calendar Year 2005:
two of the four required LPNs and a licensed physician.

G.L c. 13, s. 13, authorizes the Board to protect the health, safety and welfare of the citizens of
the Commonwealth through the regulation of nursing practice and education. The Board’s
public protection mandate is carried out in a variety of ways including initial and renewed nurse
licensure, and the establishment of standards for the operation of nursing education programs
that prepare graduates for practice as an RN or LPN. The Board is also responsible for the
enforcement of the laws and regulations governing nursing practice. One means by which the
Board accomplishes this is through its evaluation of and action on complaints filed with the
Board regarding an individual nurse’s practice. Complaints are submitted by employers and
other regulatory agencies such as the Division of Health Care Quality and the state Drug Control
Program, and less frequently by patients, their family members and other concerned individuals.

Based on its investigation, the Board may dismiss a complaint or impose remedial requirements
(commonly referred to as discipline) in the form of a reprimand, probation, suspension,
surrender or revocation of a nurse’s license to practice nursing. A reprimand, the lowest form
of remedial action, is a formal acknowledgment by the Board to the nurse that a practice-related
error was made. It is designed to focus the nurse’s attention on the specific aspect of practice-
related breakdown. A reprimand places no restrictions on the nurse’s license or ability to
continue to practice. Alternatively, a nurse whose license to practice is placed on probation by
the Board may continue to practice nursing in Massachusetts. The nurse placed on probation
must practice under Board-specified terms and conditions (e.g., remedial education and
supervised practice).

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B. Complaint Resolution Activities
A total of 125,787 nurses (106,165 RNs and 19,622 LPNs) held current Massachusetts nurse
licensure as of December 31, 2005. Between January 1, 2005, to December 31, 2005 (CY
2005), the Board evaluated and resolved 661 complaint cases. This represents only 0.5% of the
total number of all Massachusetts-licensed nurses as of December 31, 2005. Each case
involved a complaint received by the Board alleging that a nurse had engaged in conduct
related to the practice of nursing that violated legal or professional standards. The categories of
these allegations, as identified on receipt by the Office of Investigation, Division of Health
Professions Licensure (DHPL), were varied and included, as examples, conduct related to a
nurse’s clinical competency, drug diversion, drug abuse, and fitness to practice.

The Board’s duty as well as its goal in investigating and evaluating complaints is to protect the
public, not to punish the nurse who makes an error. In each of the 661 complaint cases closed
in CY 2005, the Board sought to determine the existence of a practice error and when needed,
to implement remedial requirements that would promote the nurse’s return to safe, competent
practice. Of the 661 complaints that it evaluated in CY 2005, the Board dismissed 380 (57.5%)
of the complaint cases based on the Board’s determination that the conduct complained of did
not warrant disciplinary action. The Board imposed remedial actions in 272 (41.1%) complaint
cases including 50 reprimands (7.6%), 49 probations (7.4%), 18 suspensions (2.7%) and 59
revocations (8.9%) in the interest of public safety. The nine (1.4%) remaining complaint cases
included those in which a nurse’s license had been placed on hold in accordance with the
licensee’s consent agreement, and duplicate cases.

The Board’s determinations that Board-imposed remediation in any form was not warranted
were based on its consideration of substantial evidence regarding: the nature and related
circumstances of the nurses conduct, applicable remedial activities successfully completed by
the nurse, employment performance evaluations of the nurse prior to and following the error,
any acknowledgment by the nurse of the practice error and its significance, prior repeated or
continuing practice-related issues, associated practice environment or systems-related factors
and the need for an official record of the nurse’s practice-related error in the public interest.
Appendix 1 provides a summary by allegation category3 and Board action on the 661 complaint
cases closed in CY 2005.

3 Classified by the DHPL as a Nature Code
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3. Methodology

The study used a case analysis method to examine the incidence and nature of certain nursing
errors by RNs and LPNs in selected complaint cases closed by the Board in CY 2005.
Specifically, it analyzed sample complaint cases to:
1. Describe the characteristics of the nurse, patient and setting;
2. Categorize the nursing errors and harm outcome;
3. Examine possible causative or contributing factors at two levels: the nurse and practice
environment;
4. Identify actions taken by the nurse’s employer and the Board, or both, in response to the
nursing error; and
5. Recommend evidence-based error prevention strategies for use by individual nurses,
nurse educators and employers, and regulatory agencies to reduce or prevent the
occurrence of nursing errors.

For the purpose of this study, a nursing error was defined as the failure of a planned nursing
action to be completed as intended or use of a wrong nursing plan to achieve an aim4.

A. Study Sample
The study sample was selected by initially applying a three-tiered selection process to the 661
complaint cases closed in CY 2005; the cases involved 442 (64%) RNs and 239 (36%) LPNs.
The first tier criterion required the selection of those complaint cases that were assigned one of
five allegation codes5: Failure to Adhere to Practice Standards, Medication Administration Error,
Unprofessional Practice, Patient Neglect and Improper Documentation of Controlled
Substances. Of the 661 complaint cases, a total of 345 met the first tier criterion.

The second tier criterion was applied to the 345 complaint cases to exclude cases that involved
conduct that had originally resulted in discipline in another state, that involved drug diversion,
drug and alcohol abuse or impaired practice, or that were dismissed based on insufficient
evidence, lack of evidence or admission to the Board’s Substance Abuse Rehabilitation
Program. One hundred and fifty-two (152) of the 345 complaint cases that met the first tier
criterion, remained after the second tier exclusion criteria was applied.

The third tier criterion was applied to the 152 complaint cases and required the presence of a
nursing error as identified from a review of the case file and excluded complaint cases in which
there was purposeful or malicious conduct. Additional cases involving alcohol and drug abuse
were identified and excluded during the review of case files at this tier. Of the 152 complaint

4 Adapted from the Institute of Medicine’s 1999 To Err Is Human, Building a Safer Health System in which an error
is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an
aim. Source: Kohn, L., Corrigan, J., & Donaldson, M. (Eds). (1999). To err is human: Building a safer health
system. Washington, DC: National Academy Press. Retrieved July 5, 2006 from the World Wide Web:
http://fermat.nap.edu/openbook.php?record_id=9728&page=210.
5 Selected by identifying the 10 most commonly occurring allegation categories (referred to as nature codes)
assigned to complaint cases that were closed by the Board during CY 2005 (major and minor medical errors were
combined into one code, “medication administration error”) and eliminating those nature codes that involved
purposeful, malicious conduct, drug diversion or drug and alcohol abuse (i.e. Drug Diversion, Patient Abuse,
Discipline in Another Jurisdiction, Drug Abuse and Practicing While Impaired). The allegation is categorized when
the complaint is first received by the Board. The allegation category or nature code is assigned by the Supervisor,
DHPL Office of Investigation, a masters-prepared nurse with 32 years of nursing experience.
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