Scenario

The Board of Nursing in your state has decided to utilize a tool developed by the National Council of State Boards of Nursing called the Taxonomy of Error, Root Cause Analysis Practice- Responsibility (TERCAP). Your nurse manager has provided you with a summary of the completed TERCAP report by your Board of Nursing’s Disciplinary Action Committee. She has asked you to review this summary and to develop a proposal of suggestions for continuing education topics on ways to minimize legal risks for your hospital’s practicing nurses. The nurse educators will develop an education series based upon your recommendations. Refer to Minnesota Boards of Nursing.

Instructions

Prepare a proposal based on the summary of the TERCAP with recommendations and suggestions on minimizing legal risks that:

Part One – Review summary of completed TERCAP report below.

A patient, aged 54, admitted for back surgery secondary to compressed vertebrae and intense pain. The difficulty with pain management has caused the patient some depression and insomnia over the last month. During her first post-operative day, the patient fell attempting to go from the bed to the bathroom without assistance. Her injury was serious and involved significant harm requiring two additional days of hospitalization and an addition six weeks of physical therapy.

A review of the case determined that her assigned nurse on night shift was an RN (age 24) with nine months of experience in this unit. This was her third 12 hours shift in a row, and she was 29 weeks pregnant. There were 28 beds occupied with only two RNs and one patient technician, due to one vacancy and a call-in for illness. This community facility has experienced a turnover rate of 12% in the last year (community average of 4.5%), and has a high number of new graduates working on medical surgical units, particularly on the 7 pm- 7 am shift.

A review of the chart showed that the patient had been advised by the out-going nurse, who admitted her to the unit post-operatively, that she needed to ask for assistance with toileting for at least the next 24 hours due to the extensive back surgery and post-anesthesia response and pain medication. The RN coming on shift had received bedside shift report at 7 pm and noted the patient sleeping, so the issue of patient assistance was not repeated. She checked on her again at 8 pm and administered the requested prn medication (morphine) for pain. She was busy with other patients and did not see the patient again until the patient fell at 9:51 pm.

The patient reported that she did not recall having been instructed to ask for assistance, as she was very groggy from the anesthesia. She stated that she had pushed the nurse call button for assistance and “no one came.” There was no clerical support at the nursing station and the three staff members had been very busy with patients, so this statement could not be substantiated.

The risk manager found that the RN had not followed nursing policy for patient assessment 20 minutes after receiving pain medication, and had not done the recommended hourly rounding on the patient to assess for the need for elimination, pain, and patient comfort. The note in the chart indicated only that the patient requested pain medication, but did not provide specific nursing assessment details or comment that the patient had received the same dosage of morphine two hours earlier.

Part Two – Factors and Actions

• Discusses the factors that contributed to event and how these factors could be addressed to minimize legal risks.
  • Situational factors
  • Nursing factors
  • Human factors
  • Organizational factors
• Explains whether the nurse was negligent or did her actions reach the level of malpractice and support your reasoning with research.
• Determines what options the nursing board had regarding this nurse’s license to practice nursing.
• Describes your reasoning for what action would you recommend (warning, probation, revocation of license) if you were on the disciplinary committee of your Board of Nursing.
• Explains how the level of nursing behavior relates to your proposed recommendation on licensure.

Part Three – Continuing Education

• Summarizes a list of topics to be provided to the education department based on the summary of the TERCAP report.
• Provides stated ideas with professional language and attribution for credible sources with correct APA citation, spelling, and grammar in the proposal.

Resources

Library Databases

• Health Policy Reference Center

Websites and Resources

• Make sure to refer to your own state’s Board of Nursing guidelines for practice and reporting requirements. Board of Nursing’s actions regarding nursing complaints and their decisions are publicly available on their website.
• TERCAP Resource Document