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Texas Board of Nursing
Nursing Peer Review Evaluation of
Practice-breakdown (N-PREP)
Katherine Thomas, MN, RN, FAAN
Execuve Director
www.bon.texas.gov
Texas Board of Nursing
Nursing Peer Review Evaluation of Practice-breakdown (N-PREP)
Contents
I. Overview and Purpose 1
II. Directions
1
III. Determination of Unprofessional Conduct and Mandatory Reporting
2
IV. Nursing Practice Breakdown
2
V. Nurse, Patient and System Factors Involved in the Nursing Practice Breakdown
5
a. Nurse Characteristics 5
b. Patient Characteristics
6
c. System Factors
7
VI. Determination of Reporting
9
Appendix A: 11
11
12
12
13
15
16
17
18
Nurse, Patient and System Factors Involved in the Nursing Practice Breakdown Examples
System Factors
Leadership & Management Factors
Communication Systems Factors
Environmental Factors
Backup & Support Factors
Staff ng Issues
Health Team Members Involved in the Nursing Practice Breakdown
Health Care Team Factors 20
Appendix B: 21
Remediation Topics Addressing Nursing Practice Breakdown
21
Appendix C: 22
Additional Resources 22
References 22
Nursing Practice Act: Texas Occupations Code 22
Board Rules: Texas Administrative Code (Title 22, Part 11, Chapter 217) 23
Nursing Peer Review 23
Minor Incident 23
Nursing Practice: 24
Nursing Practice Breakdown: 24
Suggested Remediation Courses: 25
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I. Overview and Purpose
Nursing Peer Review is required by the Texas Nursing Practice Act (NPA) to promote the delivery of safe,
quality nursing care. Nursing Peer Review Committees (Committee) are called upon to fact nd, investigate,
and analyze nursing practice breakdo
wn events that may indicate there is a decit in the nurse’s ability to
provide safe nursing care. The Texas NPA and Board of Nursing’s (Board) rules govern nurses in providing
safe nursing care and include the Standards of Nursing Practice (Board Rule 217.11)
1
, Unprofessional
Conduct (Board Rule 217.12)
2
and mandatory reporting requirements (NPA 301.401).
3
This is an optional resource offered by the Texas Board of Nursing and is intended to support a
Committee’s analysis of reported incidents to determine if a nurse’s action(s):
is required to be reported to the Board
constitutes a minor incident that is not required to be reported to the Board and may be remediated
does not constitute a decit in practice
In addition to the regulations outlined above, the Committee should also be very familiar with Board Rule
217.19, related to Incident-Based Nursing Peer Review
4
and Board Rule 217.16, related to Minor Incidents.
5
Each Committee is encouraged to collect and analyze information obtained through this resource to promote
patient safety and the quality of nursing care. As such, the resource may be tailored to meet specic
organizational needs. However, Sections III, IV, and VI regarding the Board’s rules about the reporting of
infractions of the Nursing Practice Act, standards of nursing practice, and unprofessional conduct should not
be modied.
II. Directions
This resource acts as template for evaluating the nursing practice breakdown event. Each section of this
instrument provides direction related to that section and how it ts into the larger picture of analyzing the
nursing practice breakdown.
The Committee should follow the resource for a thorough evaluation of the event. However, the Committee
members may determine that reporting to the Board is required without the need to exhaust the steps
outlined in this resource based on an evaluation of known facts about the events surrounding the nursing
practice breakdown. In this situation, the Committee members may wish to go directly to the mandatory
reporting sections in Section III and VI. In instances where the nurse is reported to the Board prior to use of
this resource, the Committee should conduct its review of system factors and/or external factors beyond the
nurse’s control by proceeding to Section V(b-c).
4
As indicated, the Nursing Peer Review of Practice-breakdown (N-PREP) is a voluntary resource for the
nursing peer review process and the information gleaned from this analysis is intended for facility level use.
It is strongly recommended that utilization of N-PREP is preceded by reviewing an orientation module
that provides a thorough explanation of the resource. This orientation can be found on the Board
website at www.bon.texas.gov. under the Practice heading then selecting from the drop-down menu
Nursing Peer Review Evaluation of Practice-breakdown (N-PREP).
Texas Board of Nursing
Nursing Peer Review Evaluation of Practice -breakdown (N-PREP)
Clear Entire Form
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III. Determination of Unprofessional Conduct and Mandatory Reporting
When the Committee’s evaluation determines that the answer to either of the following two questions is
“Yes,” then the Board’s mandatory reporting requirements
3
have been met and the Committee is required to
report the nurse to the Board.
1. Did the nurse’s conduct cause a person to suspect that the nurse’s practice is impaired by chemical
dependency or drug or alcohol abuse?
2. Did the nurse’s conduct constitute abuse, exploitation, fraud, or a violation of professional
boundaries?
IV. Nursing Practice Breakdown
1,2
After screening to determine if the event constitutes a mandatory report of the nurse to the Board, this
section analyzes the nursing standards that apply to the nursing practice breakdown event. The Committee
should keep in mind that nursing practice breakdown is dened as the disruption or absence of any of the
aspects of good practice in which the standard of nursing care was not met.
6
This section lists various types
of nursing practice breakdown, based on the Texas Board of Nursing Standards of Nursing Practice (Board
Rule 217.11)
1
and the Board’s Unprofessional Conduct Rule (Board Rule 217.12)
2
, to help identify which
types of nursing practice breakdown(s) occurred. If there have been prior minor incidents, review these in
conjunction with the current nursing practice breakdown event.
What was the nursing practice breakdown event?
Describe the who, what, when, and where of the nursing practice breakdown event.
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Board Rule 217.11 Standards of Nursing Practice
From the list below, identify any and all practice standards found in Board Rule
217.11 that were not met during the nursing practice breakdown event.
Know and conform to the Texas Nursing Practice
Act and the Board’s rules and regulations as
well as all federal, state, or local laws, rules or
regulations affecting the nurse’s current area of
nursing practice.
Implement measures to promote a safe
environment for clients and others.
Know the rationale for and the effects of
medications and treatments and shall correctly
administer the same.
Accurately and completely report and
document: the client’s status including signs and
symptoms; nursing care rendered; physician,
dentist or podiatrist orders; administration of
medications and treatments; client response(s);
and contacts with other health care team
members concerning signicant events
regarding client’s status.
Respect the client’s right to privacy by
protecting condential information unless
required or allowed by law to disclose the
information.
Based on health needs, promote and
participate in education and counseling to a
client(s) and, where applicable, the family/
signicant other(s).
Obtain instruction and supervision as necessary
when implementing nursing procedures or
practices.
Make a reasonable effort to obtain
orientation/training for competency when
encountering new equipment and technology or
unfamiliar care situations.
Notify the appropriate supervisor when leaving
a nursing assignment.
Know, recognize, and maintain professional
boundaries of the nurse-client relationship.
Provide, without discrimination, nursing services
regardless of the age, disability, economic
status, gender, national origin, race, religion,
health problems, or sexual orientation of the
client served.
Institute appropriate nursing interventions
that might be required to stabilize a client’s
condition and/or prevent complications.
Clarify any order or treatment regimen that
the nurse has reason to believe is inaccurate,
non-efcacious or contraindicated by consulting
with the appropriate licensed practitioner and
notifying the ordering practitioner when the
nurse makes the decision not to administer the
medication or treatment.
Implement measures to prevent exposure
to infections pathogens and communicable
conditions.
Collaborate with the client, members of the
health care team and, when appropriate, the
client’s signicant other(s) in the interest of the
client’s health care.
Consult with, utilize, and make referrals to
appropriate community agencies and health
care resources to provide continuity of care.
Be responsible for one’s own continuing
competence in nursing practice and individual
professional growth.
Make assignments to others that take into
consideration client safety and that are
commensurate with the educational preparation,
experience, knowledge, and physical and
emotional ability of the person to whom the
assignments are made.
Accept only those nursing assignments that
take into consideration client safety and that
are commensurate with the nurse’s educational
preparation, experience, knowledge, and
physical and emotional ability.
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Supervise nursing care provided by others for
whom the nurse is professionally responsible.
When acting in the role of nurse administrator,
ensure the verication of current Texas licensure
or other Compact State licensure privilege and
credentials of personnel for whom the nurse is
administratively responsible.
Perform nursing assessment(s) within the scope
of practice for the licensure level.
Develop or participate in the development of
the nursing plan of care within the scope of
practice for licensure level.
Implement nursing care within the scope of
practice for the licensure level.
Evaluation of client’s response(s) within the
scope of practice for the licensure level.
(For RNs, including APRNs ONLY) Delegate
tasks to unlicensed personnel in compliance with
the appropriate Board of Nursing Rules and
Regulations chapter of delegation rule (Chapter
224 or Chapter 225).
7
(For APRNs ONLY) Prescribe medications in
accordance with prescriptive authority granted
under Board Chapter 222
8
and standards
within that chapter and in compliance with state
and federal laws and regulations relating to
prescription of dangerous drugs and controlled
substances.
Carelessly failing, repeatedly failing, or
exhibiting an inability to perform vocational,
registered, or advanced practice nursing in
conformity with the standards of minimum
acceptable level of nursing practice set out in
Rule 217.11.
Conduct that may endanger a client’s life, health
or safety.
Threatening or violent behavior in the
workplace.
Demonstrating actual or potential inability to
practice nursing with reasonable skill and safety
to clients by reason of illness, use of alcohol,
drugs, chemicals, or any other mood-altering
substances, or as a result of any mental or
physical condition.
Misappropriating, in connection with the
practice of nursing, anything of value or benet,
including but not limited to, any property, real
or personal of the client, employer, or any other
person or entity, or failing to take precautions
to prevent such misappropriation.
Falsication of or making incorrect, inconsistent,
or unintelligible entries in any agency, client, or
other record pertaining to drugs or controlled
substances.
Failing to follow the policy and procedure
in place for the wastage of medications at
the facility where the nurse was employed or
working at the time of the incident(s).
Obtaining or attempting to obtain or
deliver medication(s) through means of
misrepresentation, fraud, forgery, deception
and/or subterfuge
Board Rule 217.12 Unprofessional Conduct
2
Unprofessional Conduct Rule 217.12 identies behaviors in practice that are likely to deceive, defraud
or injure clients. Actual injury to a client need not be established. The behaviors outlined below
do not incorporate all of aspects of 217.12 but are those that most often relate to nursing practice
breakdown and are not covered by other sections of this N-PREP Resource. Identify any and all
unprofessional conduct in this section that occurred during the nursing practice breakdown event.
2
When determining whether or not a report to the Board is needed, the Committee should carefully
evaluate the nurse’s behavior including intent, as well as the nature, seriousness and implications
of the conduct.
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V. Nurse, Patient, and System Factors Involved in the Nursing Practice Breakdown
9
Improvement in patient safety will not be accomplished by focusing on discrete errors alone.
6
Concurrent
with the review of the nursing practice breakdown, there should be a review of those factors in the health
care system that may have also contributed to the error event. This instrument provides a comprehensive
template for the selection of factors that contributed to the event including nurse, patient, system and
healthcare team factors. The Committee may then determine the appropriate course of action regarding
remediation.
a. Nurse Characteristics
This section describes the nurse involved in the nursing practice breakdown and obtains characteristics about
that nurse that should be taken in consideration related to the nursing practice breakdown as the Committee
analyzes the event. Consider additional/other nurse data as appropriate to tailor to your facility needs.
1. What is the highest nursing degree held by the
nurse at the time of the nursing practice break
down?
Diploma
ADN
Alternate Entry
BSN
Graduate
Vocational Certicate
Unknown
2. What is the highest licensure level held by
the nurse at the time of the nursing practice
breakdown?
LVN
RN
APRN
Unknown
3. What is the year of the nurse’s initial licensure
at their highest licensure level, if known?
____________________
4. Was the nurse on orientation at the time of the
nursing practice breakdown?
Yes No
5. Length of time the nurse worked in the patient
care location/unit/department where the nursing
practice breakdown occurred.
Less than one month
1-11 months
1 yr-less than 3 yrs
3 yrs- less than 5 yrs
5 yrs or more
Unknown
6. What type of shift was the nurse working at
the time of the nursing practice breakdown?
This information will help determine if there are
particular types of shifts where more nursing
practice breakdown occurs.
8 hour
10 hour
12 hour
On Call
Other____________
Unknown
7. Was the nurse working in a temporary capacity
(i.e. traveler, oat pool, oat to another unit, or
covering a patient for another nurse)? Nurses in a
temporary capacity may not be familiar with the
environment or be as experienced with the type of
nursing care.
Yes No Unknown
8. What was the nurse’s patient assignment at
the time of the nursing practice breakdown?
Consider the number of patients assigned and
their acuity.
No patients
Less than usual patient load
More than usual patient load
Usual patient load
Unknown
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b. Patient Characteristics
9
This section examines characteristics of the patient involved in the nursing practice breakdown event.
Collecting and aggregating this data provides the opportunity to identify common patient characteristics
that may contribute to nursing practice breakdown. Consider additional/other patient data as appropriate,
to tailor to your facility needs. Please check all that apply. *Notes questions that have examples provided in
Appendix A.
9. Patient age.
______________ Unknown
10. Patient sex.
Male
Female
Other
Unknown
11. Patient’s diagnosis. The patient’s diagnoses
may contribute to the context of nursing practice
breakdown.
Endocrine, metabolic, & immune systems
disease/ disorder
Genitourinary system disease/ disorder
Heart & circulatory system disease/ disorder
Mental health conditions
Musculoskeletal system disease/ disorder
Nervous system or sense organ disease/
disorder
Pregnancy, childbirth, & related conditions/
complications
Injury/ trauma
Respiratory system disease/ disorder
Skin disease/ disorder
Systemic infections/ infectious diseases
(bacterial, viral, & parasitic)
Other__________
12. What was the complexity of the patient
involved at the time of the nursing practice
breakdown? The complexity of the patient may
affect or contribute to nursing practice breakdown.
Less complex than the average
Average complexity
More complex than average
13. Characteristics the patient exhibited that were
involved in the nursing practice breakdown.
Agitation/ combativeness/violence
Altered level of consciousness
Communication/ language difculty
Depression/ anxiety
Inadequate coping/ stress management
Incontinence
Insomnia
Cognitive Impairment
Pain
Sensory decits (hearing, vision, touch)
Other___________
14. Impact of the nursing practice breakdown on
the level of patient harm.*
No harm
Harm
Serious Injury
Death
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c. System Factors
9
System factors are elements found within an organization and may be beyond the nurse’s control that impact
nursing practice. Examining components of the system that may have contributed to the nursing practice
breakdown provides the opportunity to address those system factors and prevent similar nursing practice
breakdown in the future. Consider additional/other nurse data as appropriate, to tailor to your facility needs.
Please check all that apply. *Notes questions that have examples provided in Appendix A.
Leadership & Management Factors
15. Did factors related to leadership and
management contribute to the nursing practice
breakdown? The leadership and management
style of hospital authorities, chief nursing ofcers,
and administrators can impact patient safety
within the organizational culture.*
Inadequate supervision/support by others
Unclear scope and limits of authority/
responsibility
Inadequate/ outdated policies/ procedures
Assignment or placement of inexperienced
personnel
Nurse shortage, sustained, at institutional level
Inadequate patient classication (acuity) system
to support appropriate staff assignments
Other____________
Communication Systems Factors
16. Did factors related to communication systems
contribute to the nursing practice breakdown? The
transfer (or lack of transfer) of patient information
is frequently cited in the patient safety literature as
a critical element in providing safe and effective
patient care.*
Communication systems equipment failure
Interdepartmental communication breakdown/
conict
Shift change (patient hand-offs)
Patient transfer (hand-offs)
Inadequate channels for resolving
disagreements
Preprinted orders inappropriately used (other
than medications)
Medical record/ electronic health record not
accessible
Patient name similar/ same
Patient identication failure
Lack of or inadequate orientation/ training
Computer system/ technology failure
Lack of ongoing education/ training
Other___________
Environmental Factors
17. Did environmental factors contribute to the
nursing practice breakdown? The environment is
a component of the organization that provides the
context for the delivery of safe patient care.*
Poor lighting
Increased noise level
Frequent interruptions/ distractions
Lack of adequate supplies/ equipment
Equipment failure
Physical hazards
Multiple emergency situations
Similar/ misleading labels (other than
medications)
Disaster
Code situation
Other_____________
Backup & Support Factors
18. Did backup and support factors play a role in
the nursing practice breakdown? Having resources
in place for the unexpected is an important
consideration in providing health care services.*
Ineffective system for provider coverage
Lack of adequate provider response
Lack of nursing expertise system for support
Forced choice in critical circumstances
Lack of adequate response by lab/ x-ray/
pharmacy or other department
Other___________
Stafng Issues
19. Did stafng issues contribute to the nursing
practice breakdown? Stafng involves a
multifocal approach to ensure safe patient care.*
Lack of supervisory/ management support
Lack of experienced nurses
Lack of nursing support staff
Lack of clerical support
Lack of other health care team support
Other___________
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Health Team Members Involved in the Nursing
Practice Breakdown
20. Did a member of the health care team
contribute to the nursing practice breakdown?
Multidisciplinary teams work together to provide
patient care. Another member of the health care
team may have contributed to the nursing practice
breakdown of the nurse in question.*
Supervisory nurse/ personnel
Physician (may be attending, resident, or other)
Other prescribing provider
Pharmacist
Additional staff nurse
Floating or temporary staff
Other health professional (e.g. PT, OT, RT)
Health profession student
Medication assistant
Other support staff
Unlicensed assistive personnel (nurse aide,
certied nursing assistant, CNA or other titles
of non-nurses who assist in performing nursing
tasks)
Patient
Patient’s family/ friend
Other____________
Healthcare Team Factors
21. Was there a healthcare team factor involved
in the nursing practice breakdown? This question
provides an opportunity to identify factors relating
to the culture of a facility and how members of
the health care team interact with each other.*
Intradepartmental conict/ non-supportive
environment
Breakdown in health care team communication
Lack of multidisciplinary care planning
Intimidating/ threatening behavior
Lack of patient involvement in plan of care
Care impeded by policies or unwritten norms
that restrict communication
Majority of staff had not worked together
previously
Lack of patient education
Lack of family/ caregiver education
Other____________
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VI. Determination of Reporting
3,4
Each section of this resource should be analyzed to identify and weigh the various characteristics and
factors that played a role in the nursing practice breakdown event. For example, if there were standards
that were not met, did the nurse take appropriate measures to try and meet the standards? Reecting
on the Committee’s evaluation of each of the sections in the N-PREP, the following are questions to aid the
Committee in reporting systems factors and determining whether or not a nurse is subject to being reported
to the Texas Board of Nursing. The questions will include instructions for how the committee is to proceed
based on their determination.
22.
Were there any system factors and/or
external factors beyond the nurse’s control that
may have contributed to the nursing practice
breakdown?
If YES, these ndings must be reported to the
Patient Safety Committee and if the facility
does not have a Patient Safety Committee the
report should go to the CNO. Continue to next
question.
If NO, continue to next question.
23. Was there a decit in the nurse’s practice
including any identied issues related to 217.11
and 217.12 in Section V that contributed to the
nursing practice breakdown?
If NO, report to the Board not needed.
If YES, continue to next question.
24. Did the nurse’s practice breakdown contribute
to the death or serious injury of the patient?
If YES, the nurse must be reported to the
Board.**
If NO, continue to next question.
25. Did the nurse’s practice breakdown indicate
that the nurse lacked knowledge, skill, judgment,
or conscientiousness to such an extent that the
nurse’s continued practice of nursing could
reasonably be expected to pose a risk of harm to
a patient or another person, regardless of whether
the conduct consists of a single incident or a
pattern of behavior?
If YES, and the Committee determines the
nurse’s continued practice of nursing could
pose a risk of harm to a patient or another
person then the nurse must be reported to the
Board.**
If NO or further evaluation is needed to
determine if the nurse’s continued practice poses
a risk of harm to a patient or another person
then continue to next question.
26. Can the nurse be remediated to correct the
deciencies identied in the nurse’s judgement,
knowledge, training or skill?
If NO, the nurse must be reported to the
Board.**
If YES, continue to the next question.
27. What remediation will be used? Refer to the
specific type of breakdown in the nurse’s practice
as determined in Section IV to develop the
remediation plan. In addition, further assistance
with remediation can be found in Appendix
B
which provides a framework that may be useful in
identifying the precipitating causes of the nursing
practice breakdown.
If the Committee determines a remediation plan is
appropriate for this event, tracking needs to occur
to ensure the nurse completes the remediation and is
deemed safe to practice. If the nurse completes the
remediation plan, documentation should be retained.
If the remediation plan is not completed or the nurse
terminates employment prior to its completion, a
determination should be made at that point in time:
• if the nurse has completed sufcient
remediation to be deemed safe to practice;
• if a report should be made to the nursing peer
review committee of the nurse’s new employer
(with the nurse’s consent); or
• if a report to the Board is needed.
**When the Committee determines it is required to
report a nurse to the Board, the Committee shall
submit to the Board a written, signed report that
includes the following requirement information per
Board Rule 217.19(i)(4).
• The identity of the nurse
• A description of the conduct subject to
reporting
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• A description of any corrective action taken
against the nurse
• A recommendation as to whether the Board
should take formal disciplinary action
against the nurse, and the basis for the
recommendation
• The extent to which any deciency in care
provided by the reported nurse was the result
of a factor beyond the nurse’s control and
• Any additional information the Board
requires.
The Board’s forms are not required to make a report
but may be used to meet the requirements found
in Board Rule 217.19(i)(4). Those forms can be
found on the Board website under Discipline and
Complaints then selecting from the drop down menu
How to File a Complaint.
• Written complaint form for Nursing Peer Review
Committees
If a determination has been made to report the
nurse to the Board, the Committee may submit
the ndings of the N-PREP review as supporting
documentation to the Board’s required reporting
information.
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Appendix A
Section V: Nurse, Patient and System Factors Involved in the Nursing Practice Breakdown
Examples
7
14. Impact of the nursing practice breakdown on the level of patient harm.
NO HARM
An error occurred but with
no harm to the patient.
Examples:
Nurse Trevor received an order to start an IV. As he was preparing
the solution in the Medication Room, Nurse Joan observed that the
solution was D5W instead of the ordered Normal Saline solution.
Nurse Carla failed to administer a patient’s medication, but the
patient did not experience any ill effects.
Nurse Mary did not thoroughly assess the patient’s changing
condition, but the following shift identied the situation quickly and
intervened before the patient deteriorated.
HARM
An error occurred that
contributed to a minor
negative change in the
patient's condition.
Examples:
Nurse Colleen forgot to turn on the alarm for the patient’s pulse
oximetry. The patient’s O2 saturation decreased to 90% requiring
the patient to remain on oxygen for a longer period.
Nurse John made a medication error that required a transfer to a
higher level of care in the ICU.
SERIOUS INJURY
An error occurred that
contributed to signicant
harm which involves
serious physical or
psychological injury.
Examples:
Nurse Margaret administered a second dose of a penicillin type
antibiotic without verifying the patient’s allergy status. The patient
suffered an anaphylactic reaction and respiratory arrest requiring
cardiopulmonary resuscitation and transfer to the ICU.
Nurse Steve failed to assess the feet of a diabetic patient; the patient
developed a wound resulting in foot amputation.
DEATH
An error occurred that
may have contributed to or
resulted in patient death.
Examples:
Nurse Sharon failed to assess a patient who appeared to be sleeping;
the charge nurse assessed the patient and discovered the patient had
suffered a respiratory arrest and was dead.
Nurse Robbie calculated a conversion incorrectly and gave ten times
the dose of a medication resulting in the patient’s death.
Nurse Andrea misread the type of insulin and gave the wrong type/
strength resulting in the patient’s death.
APPENDIX A:
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Appendix A
15. Did leadership and management factors contribute to the nursing practice breakdown?
Inadequate supervision/
support by others
Examples:
Preceptor Amy did not monitor new nurse Bill performing a treatment
for the rst time; Bill did not follow the facility procedure resulting in
an error.
Nurse Joan was oated to a unit that she had never worked before
and given a very unstable patient by the charge nurse. The charge
nurse did not respond to a request for help from Nurse Joan.
Unclear scope and
limits of authority/
responsibility
Examples:
Nurses were unclear as to their roles in directing EMTs working in the
Emergency Department.
Staff were unclear regarding ICU nurses and respiratory care
therapist roles and responsibilities in the operation and maintenance
of ventilators.
Inadequate/ outdated
policies/ procedures
Examples:
The equipment that was being used did not align with the facility
policies and procedures.
Emergency policies were not current with ACLS training and
certication thus causing confusion during a code.
The APRN’s delegation protocol referenced the use of the most
current edition of the text “Clinical Guidelines in Family Practice” for
determining the standard of care. The only available copy of this text
for the APRN’s use was an older edition of the text.
Assignment or placement
of inexperienced
personnel
Example:
An adult medical-surgical nurse was oated to a pediatrics unit and
was not given an orientation to the unit.
Nurse shortage,
sustained, at institution
level
Example:
For several weeks, a hospital had a continually high census and was
not staffed with a full complement of nurses. The problem became
critical when there was a serious and sustained increase in patient
acuity.
Inadequate patient
classication (acuity)
system to support
appropriate staff
assignments
Examples:
The lack of a valid and reliable patient classication system resulted
in inadequate stafng.
The acuity classication system had been revised numerous times to
the point that the nurse making the assignments was confused.
System Factors
Leadership & Management Factors
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Appendix A
16.
Did communication systems factors contribute to the nursing practice breakdown?
Communication systems
equipment failure
Example:
The nurses’ intercom call light system frequently malfunctioned
resulting in patients being unable to summon assistance.
Interdepartmental
communication
breakdown/ conict
Examples:
Patient units A & B staff disagreed on the process for cross training
between units; the conict affected other unit interactions.
The Emergency Department and Lab disagreed on how lab values
should be reported. The resulting confusion led to a critical lab value
being overlooked.
Shift change (patient
hand-offs)
Examples:
The lack of communication between shifts resulted in a failure to
communicate changes in a patient's condition, medication change and
new treatment.
A recent policy change required shift report to be done at the bedside.
Nurse Ellen complied with this change but because of the extra time
requirement, did not complete her documentation.
Patient transfer (hand-
offs)
Example:
Nurse Max did not call a report to the unit receiving the patient
transferred from his department.
Inadequate channels for
resolving disagreements
Example:
A nurse and a resident physician disagreed over a patient’s care;
there was no means to resolve the disagreement resulting in continued
friction between the two which impacted patient care.
Preprinted orders
inappropriately used
(other than medications)
Example:
A pre-printed order was not customized to the patient and an allergy
warning was not recorded.
Medical record not
accessible
Examples:
The unit clerk did not add the I&O sheets to the patient’s chart in a
timely manner resulting in the patient’s nurse being unable to review
the previous 24-hour totals.
The EHR system was inaccessible contributing to several missed orders.
Communication Systems Factors
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Appendix A
16.
Did communication systems factors contribute to the nursing practice breakdown? Continued
Patient name similar/
same
Example:
Two patients had the same last name, causing a mix-up in their orders.
Patient identication
failure
Examples:
The patient’s name bracelet was difcult to read. This resulted in a
nurse misidentifying the patient.
The hospital arm band scanning system did not differentiate between
two patients with the same name.
Computer system failure/
technology
Example:
Nurse Lilly was unable to check for new medical orders because the
computer system was down. The patient did not receive a one-time
Lasix dose as prescribed.
Lack of or inadequate
orientation/training
Examples:
The scheduled orientation for a new nurse included several shifts where
she would “buddy” with another nurse to provide patient care. Due to
a shortage of staff, the charge nurse assigned the nurse six patients
to care for without the buddy. The new nurse was not able to complete
the assignment and some aspects of patient care were not provided.
Nursing supervisor David, believing that experienced nurse Regina
had no need for orientation to a new practice environment, did not
schedule her for training. In the rst week Regina failed to follow the
organization’s Infection Control policy.
Lack of ongoing
education/training
Example:
New equipment was placed on the unit with no training offered or
available. All nurses were expected to use the new equipment. Nurse
Faye did not set up the equipment correctly and the patient did not
receive the ordered treatment.
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Appendix A
17.
Did environmental factors contribute to the nursing practice break down?
Poor lighting
Example:
The light in the medication room was out and Maintenance did not
respond, leading to a long delay in medication administration.
Increased noise level
Example:
Nurse Norma could not concentrate on calculating an IV dosage
because of construction on the unit; subsequently she made a
mathematical error.
Frequent interruptions/
distractions
Example:
Nurse Nancy was constantly interrupted during her morning
medication rounds and omitted one patient’s medication.
Lack of adequate
supplies/equipment
Example:
Nurse Yolanda was unable to administer a treatment because the
equipment was missing.
Equipment failure
Example:
A patient coded. The telemetry leads were cracked and did not work.
Physical hazards
Example:
Nurse Paul, while assisting a patient to ambulate, tripped over
material left in the hallway, causing both to fall.
Multiple emergency
situations
Example:
Two codes occurred at the opposite ends of the hall; there was only
one emergency cart on the unit.
Similar/misleading labels
(other than medications)
Example:
Nurse Sheila grabbed a bottle of sterile saline to use in a treatment
and did not realize that she had gotten another solution with a similar
bottle and label.
Disaster
Example:
A hurricane caused power outages and ooding within the facility,
leading to failure of the back-up generators. With poor lighting in
the unit, Nurse Matt made a central line tubal misconnection.
Code Situation
Example:
Nurse Perry misunderstood the verbal order given during a code
situation and administered the wrong dose of a medication.
Environmental Factors
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Appendix A
18.
Did backup and support factors play a role in the nursing practice breakdown?
Ineffective system for
provider coverage
Example:
The medical department did not inform the patient units that resident
physicians were unavailable to cover patient needs because of
sitting for national examinations. Nor did they notify the attending
physicians that they were to provide coverage.
Lack of adequate provider
response
Examples:
Physician Ben was notied of a critical change in the patient’s
condition and failed to issue any orders.
APRN Julia encountered a patient care situation that was beyond
her scope of practice. She attempted to text, call and page the
delegating physician, but the physician did not respond.
Lack of nursing expertise
system for support
Example:
A patient was ordered to have a procedure that none of the nurses
or supervisor on the shift had performed. No other orientation/
supervision was available so the procedure was delayed for several
hours.
Forced choice in critical
circumstances
Examples:
Nurse Sally had only worked on a Med/Surg Unit. She received a
critically ill patient on her unit because there were no ICU beds or
staff.
Nurse George received multiple trauma patients in the ED at the same
time, resulting in many patients not receiving timely assessments.
Lack of adequate
response by lab /x-ray/
pharmacy or other
department
Examples:
In a small, rural facility, there was no replacement while the lab tech
was on vacation and the Nursing Department was not notied. This
resulted in several patients missing lab work.
Stat laboratory tests were ordered but not completed by the lab in a
timely manner.
Security ofcers were summoned to assist with an agitated visitor but
did not respond to the page.
Backup & Support Factors
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Appendix A
19.
Did staffing issues contribute to the nursnig practice breakdown?
Lack of supervisory/
management support
Example:
Due to several new admissions, the supervisor did not respond to a
nurse who requested additional staff.
Lack of experienced
nurses
Example:
Enough nurses were assigned to an evening shift, but only one
regularly worked on the unit; others were oat or agency personnel.
Lack of nursing support
staff
Examples:
Housekeeping had frequent stafng issues requiring nurses to
routinely take over those responsibilities impacting their prioritization
of patient care.
A nursing assistant was regularly oated to another unit and not
replaced despite an increase in census and several critically ill
patients.
Lack of clerical support
Example:
There was no clerical help at night despite an ongoing trend in new
admissions.
Lack of other health care
team support
Example:
There was no respiratory therapist assigned to the night shift despite
multiple ventilator dependent patients needing ongoing support.
Stafng Issues
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Appendix A
20. Did a member of the health care team contribute to the nursing practice breakdown?
Supervisory nurse/
personnel
Examples:
On an extremely busy shift, charge nurse Rachel told staff she was busy
and to work out problems on their own.
Charge nurse Tony left the oor on a nonscheduled smoke break without
notifying anyone. A patient fell, and the assigned nurse needed help.
Physician (may be
attending, resident, or other)
Examples:
Ignoring hospital policy, the physician told the nurse to take a verbal
order for a medication. The nurse administered the wrong dosage of
medication because she misheard the verbal order.
A physician told the nurse, “Don’t call me - I don’t care what happens
I’ve been up for 36 hours”. Consequently, the nurse decided not to call
the physician when the patient had a serious change in condition.
Other prescribing provider
Example:
A physician’s assistant wrote admission orders for a new patient
including an order for a MRI. The patient insisted that he had the
ordered MRI the day before and did not need the procedure again.
The nurse did not check with the X-Ray Department or clarify the MRI
order with the physician’s assistant.
Pharmacist
Example:
The Pharmacy sent the wrong antipsychotic medication to the unit.
Nurse Victor failed to review the MAR before administering the
medication to the patient.
Additional staff nurse
Example:
A patient in a psychiatric setting became violent with other patients
and had to be placed in seclusion. Because of chaos on the unit, Nurse
Charles forgot to inform the physician and request an order for the
seclusion. Nurse Julie took over at shift change and, assuming that the
physician had been notied, did not notify medical staff. This resulted
in medical staff being unaware of a secluded patient for 24 hours.
Floating or temporary staff
Example:
Nurse Ruth was oated to pediatrics from L&D. She answered the
patient’s call light and provided interventions. She failed to document
or notify the assigned nurse of these actions.
Other health professional
(e.g. PT, OT, RT)
Example:
OT staff did not raise the bed rails after working with the patient.
Nurse Jean was late from her lunch break and the patient had fallen out
of the bed.
Health profession student
Example:
A medical student accidentally discontinued the wrong IV line and did
not alert the patient's nurse.
Health Team Members Involved in the Nursing Practice Breakdown
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19 of 25
Appendix A
20. Did a member of the health care team contribute to the nursing practice breakdown?
Medication assistant
Example:
Because of several new admissions, Nurse Judy asked the medication
assistant to also give medications to a few of her patients. The
medication assistant forgot to give the meds.
Other support staff
Example:
Dietary staff mistakenly delivered a tray to the unit for a patient that
had NPO orders. Nurse Veronica delivered the tray to the patient who
ate the meal. The patient’s surgery had to be postponed.
Unlicensed assistive
personnel (nurse aide,
certied nursing assistant,
CNA or other titles of
non-nurses who assist in
performing nursing tasks)
Example:
At the beginning of the shift, the nurse instructed the nurse aide to
ensure that the patient received hourly vital signs. The nurse did not
check to ensure these were done and the patient had vital signs taken
only once during the shift.
Patient
Example:
An agitated patient was continuously scratching at his telemetry leads
causing false V tach alarms. Nurse Rachel delayed checking the alarm
and discovered the patient had an actual episode of V tach.
Patient’s family/friend
Example:
Nurse Patrick administered the patient his morning medications. It was
not until later that morning that Nurse Patrick discovered the patient’s
wife had brought in his home medications and the patient had taken two
doses of his antidepressant medication.
Continued
www.bon.texas.gov
20 of 25
Appendix A
21.
Was there a healthcare team factor involved in the nursing practice breakdown?
Intradepartmental conict/
non-supportive environment
Example:
Staff were at odds over a new scheduling policy and the conict
carried over into inappropriate assignments of patient care.
Breakdown of health care
team communication
Example:
Oncoming nursing staff were not informed of a patient’s revised
advanced directives.
Lack of multidisciplinary
care planning
Example:
There was no attempt to coordinate a patient’s discharge planning and
teaching resulting in a non-ambulatory patient going home without
support.
Intimidating/ threatening
behavior
Examples:
The medical director threatened a nurse’s job if she continued to
demand better stafng for her unit.
A respiratory therapist screamed at a graduate nurse. The nurse was
so upset she failed to maintain sterile technique while performing trach
care.
Lack of patient involvement
in plan of care
Example:
A fearful patient was not given a chance to express concerns, which
resulted in inadequate care.
Care impeded by policies or
unwritten norms that restrict
communication
Examples:
The nurse was instructed to always call the night supervisor before
contacting the physician at night.
Only team leaders hear shift-to-shift report, so other staff were not
fully aware of concerns or special needs of their patients.
Majority of staff had not
worked together previously
Example:
A new cohort of graduate nurses began their rst week on the unit
at the same time as the new resident physicians began their rotation,
leading to gaps in communication.
Lack of patient education
Example:
A patient was not instructed on the correct use of medication resulting
in the patient taking the wrong dose once discharged from the hospital.
Lack of family/caregiver
education
Example:
A patient was discharged before the family members were instructed on
the use of oxygen equipment.
Healthcare Team Factors
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21 of 25
Appendix B
Remediation Topics Addressing Nursing Practice Breakdown
6,7
When the Committee has determined that the nurse has demonstrated a decit in knowledge, judgement,
skills, professional responsibility or patient advocacy and the nursing practice breakdown is a minor incident
that does not require a report to the Board, remedial activities should be developed by the facility.
The rst step in developing a plan for remediation is to evaluate the nursing practice breakdown decits
in Section IV that were identied during the review process. The remediation plan should be focused on
updating the nurse’s knowledge of current nursing theory and clinical practice to ensure competency in those
areas.
Additionally, the Committee may choose to review the following broad classications of nursing practice
breakdown, which were developed by the National Council of State Boards of Nursing [NCSBN], to
further evaluate the precipitating cause of the nursing practice breakdown event.
6
These categories are
interrelated and more than one may be selected.
1. Was Attentiveness/Surveillance a factor in the
nursing practice breakdown?
While on duty, the nurse monitors and “sees”
what is happening with the patient and staff. The
nurse is responsible for observing 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.
2. Was Clinical Reasoning a factor in the nursing
practice breakdown?
Nurses must correctly interpret patients’ signs,
symptoms, and responses to therapies. This
includes an evaluation of the any changes in
patient signs and symptoms, ensuring that patient
care providers are notied, and adjusting patient
care appropriately. Clinical reasoning includes
titration of drugs and other therapies according
to the nurse’s assessment of patient responses.
3. Was Interpretation of authorized provider’s
orders a factor in the nursing practice
breakdown?
The nurse is responsible for interpreting
authorized provider orders, and implementing
appropriate orders.
4. Was Professional Responsibility/Patient
Advocacy a factor in the nursing practice
breakdown?
The nurse must demonstrate professional
responsibility and understand 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.
5. Was Prevention a factor in the nursing practice
breakdown?
It is important that 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. Was Intervention a factor in the nursing practice
breakdown?
The nurse properly executes healthcare
procedures aimed at specic therapeutic goals.
Interventions are implemented in a timely manner.
Nurses perform the right intervention for the right
patient at the right time for the right reason.
APPENDIX B:
www.bon.texas.gov
22 of 25
Appendix C
Additional Resources Continued
References
1.
22 Texas Administrative Code §217.11 Retrieved from https://ww.bon.texas.gov/
rr_current/217-11.asp
2
. 22 Texas Administrative Code §217.12 Retrieved from https://www.bon.texas.gov/
rr_current/217-12.asp
3
. Nursing Practice Act, Texas Occupations Code §301.401 Retrieved from https://www.
bon.texas.gov/laws_and_rules_nursing_practice_act_2017.asp#_Toc498606536
4
. 22 Texas Administrative Code §217.19 Retrieved from https://www.bon.texas.gov/
rr_current/217-19.asp
5
. 22 Texas Administrative Code §217.16 Retrieved from https://www.bon.texas.gov/
rr_current/217-16.asp
6
. National Council of State Boards of Nursing. (2010). Nursing Pathways for Patient
Safety. St. Louis: Mosby Elsevier.
7. 22 Texas Administrative Code Chapter 224/225. Retrieved from https://www.bon.
texas.gov/laws_and_rules_rules_and_regulations_current.asp
8. 22 Texas Administrative Code Chapter 222. Retrieved from https://www.bon.texas.
gov/laws_and_rules_rules_and_regulations_current.asp
9
.
National Council of State Boards of Nursing. Taxonomy of Error Root Cause Analysis of
Practice (TERCAP)
®
Instrument.
Nursing
Practice Act:
Texas
Occupations
Code
Sections 301.401-301.419 related to Reporting Violations and Patient Care Concerns
Sections 303.001-303.012 related to Nursing Peer Review
APPENDIX C:
www.bon.texas.gov
23 of 25
Appendix C
Additional Resources Continued
Board
Rules: Texas
Administrative
Code (Title
22, Part 11,
Chapter 217)
§217.1, related to Denitions
§217.11, related to Standards of Nursing Practice
§217.12, related to Unprofessional Conduct
§217.16, related to Minor Incidents
§217.19, related to Incident-Based Nursing Peer Review and Whistleblower Protections
§217.20, related to Safe Harbor Nursing Peer Review and Whistleblower Protections
If the incident-based nursing peer review is related to an APRN, then consider:
§§221.1 - 221.17, related to Advanced Practice Registered Nurses
And if the APRN has Prescriptive Authority, then consider:
§§222.1 — 222.10, related to Advanced Practice Registered Nurses with Prescriptive
Authority
If the nursing peer review is related to the RN delegation of a task, then consider
rules within the applicable delegation chapter:
§§224.1 — 224.11, related to Delegation of Nursing Tasks by Registered
Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in
Acute Care Environments and/or
§§225.1 — 225.15 related to RN Delegation to Unlicensed Personnel and Tasks
Not Requiring Delegation in Independent Living Environments for Clients with
Stable and Predictable Conditions
Nursing Peer
Review
Nursing Peer Review/Incident-Based and Safe Harbor
Nursing Peer Review Frequently Asked Questions
Minor Incident
Flow Chart for Determining if an Error is a Minor Incident
Nurse Responsibilities when an Error Occurs
www.bon.texas.gov
24 of 25
Appendix C
Additional Resources Continued
Nursing
Practice:







General Practice Information
APRN Nursing Practice Information
Board of Nursing Position Statements
Scope:
 Scope- Licensed Vocational Nurse Practice
 Scope-Registered Nurse Practice
 Decision Making Model for Determining Nursing Scope of Practice
 Scope- Advanced Practice Registered Nurse
Guidelines
Delegation Resource Packet
Frequently Asked Questions (FAQs):
 Nursing Practice
 Advance Practice Registered Nurse
 Nursing Practice in Disaster Areas
 Licensure
 Discipline
 Delegation
Nursing
Practice
Breakdown:

Taxonomy of Error Root Cause Analysis of Practice-r
esponsibility TERCAP
®
 TERCAP Publications
 Benner, P., Malloch, K., Sheets, V., Bitz, K., Emrich, L., Thomas, M., Bowen, K., Scott,
K., Patterson, L., Schwed, K., & Farrell, M. (2006). TERCAP: Creating a national
database on nursing errors. Harvard Health Policy Review, 7(1), 48-63.
 Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K., & Jamison, D. (2002). Individual,
practice, and system causes of errors in nursing: A taxonomy. Journal of Nursing
Administration, 32, 509-523.
 Hudspeth, R. (2010). The importance of engaging with TERCAP: Taxonomy of error
root cause analysis and practice-responsibility. Nursing Administration Quarterly. 34,
88-89. doi: 10.1097/NAQ.0b013e3181c95f01
 National Council State Boards of Nursing. (2010). Nursing Pathways for Patient
Safety. St Louis, MO: Mosby Elsevier. ISBN 978-0-323-06517-7
 Thomas, M. (2011). TERCAP report. Presentation presented at NCSBN Annual
Meeting, Indianapolis. Retrieved from: https://studylib.net/doc/5209032/tercap-
report---national-council-of-state-boards-of-nursing
 Zhong, E. & Thomas, M. (2012). Association between job history and practice error:
An analysis of disciplinary cases. Journal of Nursing Regulation, 2(4), 16-18. doi:
10.1016/S2155-8256(15)30249-0
 Board of Nursing Quarterly Newsletter: TERCAP
 National TERCAP
 Texas Board of Nursing Collecting Information to Better Understand Nursing
Errors
 July 2009 issue (page 4)
 Texas TERCAP Pilot
 Texas TERCAP® Pilot Program Set to Start in August - Peer Review Committee
Participation Sought
 July 2012 issue (page1)
www.bon.texas.gov
25 of 25
Appendix C
Additional Resources
Nursing
Practice
Breakdown:
 Update on Texas Taxonomy of Error Root Cause Analysis of Practice-responsibility
(TERCAP) Pilot
 January 2015 issue (page 5)
 Texas TERCAP Pilot Project Update
 April 2016 issue (page1)
 Texas TERCAP Pilot Project Completed
 July 2017 issue (page1)
Suggested
Remediation
Courses:
 Texas Board of Nursing
 Online Course Catalog
 Approved Third-Party Courses
 National Council of State Boards of Nursing
 Online Courses (Learning Extension)
 Texas Health and Human Services
 Online Course Catalog of Workshops for Assisted Living Facilities, Intermediate
Care Facilities for Individuals with Intellectual Disabilities, and Nursing Facilities
With its recent release, the Board is evaluating the clarity and implementation of the N-PREP
Resource into the nursing peer review process. If you have questions about nursing peer review or
the use of the resource please email NPREP@bon.texas.gov
If you have feedback to provide the Board about efcacy of the resource please click on the
following link to complete the survey, we welcome any comments you may have.
https://www.surveymonkey.com/r/NPREPResourceFeedback
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