Presented by: Elizabeth N. Sjoberg, RN, J.D. Associate General Counsel Texas Hospital Association August 10, 2011 Application of TERCAP to Case Study

THA – Who We Are  The Texas Hospital Association is a nonprofit trade association representing Texas hospitals and health systems. In addition to providing a unified voice for health care, THA serves its 500+ members with timely information, data analysis, education on essential operational requirements, networking and leadership opportunities. 2

THA – What We Do  Since its founding in 1930, THA has grown and evolved with the hospital industry itself. Today, THA is the leading advocacy organization for Texas hospitals. The Association’s dedicated, professional staff is committed to helping hospitals navigate the complex, ever- changing legislative and regulatory environment, while working toward common solutions for better health care policy at the state and federal levels.  THA also serves as a resource for the State of Texas in the areas of disaster planning and response, data services and regulatory development. 3

THA’s Family of Companies  The THA Family of Companies provides a full range of services for hospitals and health systems: –HealthShare markets products and services offered through THA-endorsed vendors. HealthShare also manages and markets voluntary insurance programs, THA’s PDS program and the THA Retirement Plan. –Texas Hospital Insurance Exchange, managed by the Texas Hospital Insurance NetworK, a wholly owned subsidiary of THA, provides dependable, competitively priced liability insurance and workers’ compensation coverage designed specifically for the Texas health care market. –Texas Healthcare Trustees is affiliated with THA and provides an education, advocacy and leadership role for the governing board members of Texas health care organizations. –Texas Center for Quality & Patient Safety is an initiative of THA and the Texas Hospital Association Foundation focused on improving the quality of care at the bedside, and reducing costs, through evidence-based practices. –HOSPAC, composed of THA’s state and federal political action committees, is the voice for more than 355,000 health care professionals working in Texas hospitals. 4

Serving Texas Hospitals/Health Systems 5

Case Study  Sharon, a pediatric nurse for three years, comes to her pediatric patient on the night shift. The mother who has been irritable with the staff all day is asleep in a chair at the bedside; she called administration twice that day about the temperature in the room and the bad sandwich she got on a guest tray. The room is darkened and Sharon does not want to wake them. 6

 One of Sharon’s other patients is near death and the family needs a great deal of support. Once again, the unit is short staffed. A pharmacist yelled at one of the nurses earlier. Everyone has been upset. Now there are several codes in the house and the charge nurse is off the unit. 7

 This is Sharon’s fourth 12-hour shift this week and her daughter has been ill. Sharon checks her pediatric patient every hour and she is peaceful with stable vital signs. Sharon does not check the IV because it is under the blanket and the mother wakes up and says, “just leave her alone—she is finally asleep”. 8

 In the morning at shift change, the on- coming nurse finds that the pediatric patient’s peripheral IV has infiltrated and the patient requires surgery.  Sharon is referred to the nursing peer review committee. 9

Application of TERCAP Please refer to attachment: “SELECTED TERCAP® QUESTIONS”  Nurse Characteristics : 11, 12, 14  Patient Characteristics: 24  Systems Factors: 25, 26, 27, 28, 29, 30, 31  Practice Breakdown: 33, 34, 38, 39, 40, 41, 44 10

Prior to the publication of the Institute of Medicine's landmark report, To Err is Human, health care organizations engaged in investigations of events that caused harm to patients. However, few of these investigations engaged in a systems-based approach to problem solving. The focus was on individuals and mistakes, rather than on the cluster of events that had combined in an unfortunate sequence to cause an incident to occur. The emphasis of such investigations was not on prevention, but on punishment. 11

 Today, facilities and nurses have tools, like the TERCAP, that shift the focus from individuals and their mistakes to a focus on the cluster of events that combined in an unfortunate sequence to cause an incident to occur. If applicable, use of these tools can replace the once “name and blame” game and promote a culture of safety through earnest collaboration between facilities and nurses. 12