1. 2007 NCSBN IRE Fellowship Project Kathy Chastain, RN, MN, Practice Mgr. Julie George, RN, MSN, FRE, Associate Executive Director

2. Problem n Board resources may be spent needlessly on matters that do not violate nursing law n Employers and Boards have few tools to guide their analysis of events

3. Background n NC is a mandatory reporting state n Existing culture of blame for error n Need to distinguish error from intentional misconduct n NCBON strategic initiative to move toward Just Culture

4. Just Culture n Focus on behavioral choice, not outcome n Levels of risk n Systems design n Categories of: human error, at-risk behavior, and reckless behavior

5. Multi-Year Project n Year 1: Development of reporting tool to guide employers and Board staff in review of incidents n Tool to be aligned with Just Culture philosophy and existing algorithm

6. Year 1 n Work with David Marx on implementing Just Culture in NC n Collaboration with others n Literature review n Review of state regulations n Design of tool

7. Criteria Human ErrorAt Risk BehaviorsReckless Behaviors Score 0 Points1 Point2 Points3 Points4 Points5 Points Awareness Meant to do one thing but did another - accidental Considered negligible risk to patient/benefit to patient/nurse Considered minimal to moderate risk for patient/benefit to patient outweighed risk/emergent situation Considered moderate to high risk for patient/failed to utilize resources/non- emergent situation Considered moderate to high risk for patient/clearly a prudent nurse would not have done/risk to patient outweight beneift Considered high risk for patient/benefit to nurse evident/no regard for patient safety Policy/ System No policy/procedure Unintentional breech (accidental) Systems design flaw (others likely to make same error) Common practice of staff (cultural norm) – practice slightly different than policy/procedure (bending of rules) Individual practice slightly different than policy/procedure - no evidence of cultural norm (bending of rules) Failed to check policy/procedure or utilize resources prior to performing unfamiliar task Individual knowingly disregarded policy/procedure or bypassed system to achieve perceived expectations of management, patient or others Individual knowingly disregarded policy/procedure or bypassed system for own personal gain Competency Accidental event regardless of level of competency Advanced beginner, needs supervision, understands procedure but may not understand theory Competent in performing task/procedure correctly, used minor discretion in carrying out work, aware of safety issues but in this incident cut corners Proficient in performing task/procedure correctly, understands rationale of correct action yet regularly deviates from standards Proficient in performing task/procedure, is in a position to negatively influence others by action Incompetent, Individual knowingly accepted assignment to perform task/procedure without possessing the necessary knowledge/skills/abilit y and did not seek assistance Repetitive No prior counseling for practice issues Prior counseling for single non- related practice issue within last year Prior counseling for single related issue within last year Prior counseling for same issue within last year Prior counselings for various practice issues within the last year with some attempts at remediation Prior counseling for same or related issue within the last six months. No or limited evidence that remedial steps were taken by nurse to improve own practice Credibility Identified own error and self reported Readily admitted error when made aware and accepts responsibility for own action Acknowledged role in error but attributes to circumstances and/or blames others to justify actions Continued to deny responsibility until confronted with evidence Denied any responsibility despite evidence presented Evidence demonstrates individual took active steps to cover up error or failed to disclose known error

8. Options for event review: n Consultation only n Employer directed corrective action n Formal corrective action n Formal reporting

9. Year 2 n Evaluate tool through pilot project n Participating pilot hospitals must have had formal Just Culture training

10. Pilot Project n Hospitals use complaint evaluation tool to determine whether Board should be contacted for practice incidents n Differentiate incidents resulting from human error from those resulting from at-risk and reckless behaviors

11. Scenarios

12. Desired Outcomes n Common framework for review or practice events that lends itself to continuous quality improvement n Balance individual and system accountability n Consistency in how practice breakdown is reported and addressed

13. Contacts Contacts: Telephone: (919) 782-3211 n Kathy Chastain, RN, MN KathyC@ncbon.comKathyC@ncbon.com ext 227 n Linda Burhans, RN, PhD(c) Lburhans@ncbon.com ext 265Lburhans@ncbon.com n Julie George, RN, MSN, FRE Julie@ncbon.com ext 276Julie@ncbon.com