Nursing Process Review: Utilizing a Consistent Approach to Evaluate Practice Breakdowns and Patient Safety

Purpose:
Nursing Process Review (NPR) was created mirroring physician peer review. NPR focused on significant untoward events. Gaps were identified in this process. The team recognized the need for a whole systems approach that could organize data and improve analysis, preventing future practice breakdown.

Significance:
Serious quality problems continue to exist in healthcare. Historically the answer has been to take a quality management approach, education/training. Alternatively, a whole systems approach assesses the entire picture, and how all factors influenced a particular situation.

Strategy and Implementation:
A literature review for a theoretical framework was completed. The National Council of State Board of Nursing had implemented a framework that was utilizing a whole systems approach to evaluate practice breakdowns ”Taxonomy of Error, Root Cause Analysis, and Practice Responsibility” (TERCAP) ®. NPR determined that this framework could provide the foundation to accomplish the purpose of the committee: “to create the infrastructure to review the practice environment, organizational culture and systems that may contribute to patient safety, while also addressing individual areas of growth which may have led to a practice breakdown.” It was determined that NPR would be comprised of nursing leaders and clinical experts who could evaluate practice with a consistent framework focusing on patient safety. The team conducted concurrent review for 3 months utilizing the previous approach and the TERCAP® tool. Cases were discussed monthly to improve inter-rater reliability and review data.

Evaluation:
TERCAP® provided specific, systematic information regarding the nursing staff prone to practice breakdowns: 80% had less than 1 year experience in the current unit and the most frequent practice breakdown was clinical reasoning (lack of recognition of signs/symptoms/response to interventions).

Implications for Practice:
Action plans can be tailored for the individual nurse. System trends can be identified that require further action and processes implemented that improve patient safety. The environment becomes safer as nurses are supported in their role to prevent practice breakdowns or intervene before one occurs.