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National Summit on Medical Errors and Patient Safety Research
National Council of State Boards of Nursing, Inc. (NCSBN)Additional Statement, Submitted by Joey Ridenour, M.N., R.N., Board President, The National Council of State Boards of Nursing, Inc. The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summit’s goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs. Selected applicants testified at the summit as members of the witness panels. The remainder of the applicants were invited to submit additional statements for consideration by the steering committee. One of these statements follows. Disclaimer and Copyright Statements A 501 (c) 3 organization, the NCSBN membership is composed of the 61 boards of nursing in the 50 states, the District of Columbia, and United States territories. Nearly 100 years ago, these boards were established by state governments to protect the public by overseeing and ensuring the safe practice of nurses. Today, board members include consumers as well as registered, advanced practice and licensed practical/vocational nurses. The mission of NCSBN is to lead in nursing regulation by assisting member boards, collectively and individually, to promote safe and effective nursing practice in the interest of common interest and concern affecting the public health, safety and welfare. NCSBN conducts research regarding regulation and nursing practice, develops and disseminate position papers/models related to nursing practice, regulation and education, and maintains a national disciplinary data bank of nurses who have had disciplinary action taken on their licenses. NCSBN also is an authorized agent for purposes of reporting licensure action to the Health Integrity and Protection Data Bank (HIPDB). There are approximately 2.5 million nurses in the United States, the largest group of licensed health care professionals in practice. Opening Statement The National Council of State Boards of Nursing (NCSBN) appreciates the opportunity to convey its interest and ideas to the panel for the National Summit on Medical Errors and Patient Safety Research (convened by the Quality Interagency Coordination Task Force (QuIC)). NCSBN supports the collection and analysis of legitimate research that will positively impact the improvement of patient safety. We agree with our many colleagues here today that this effort must be done in concert with other stakeholders to make sure that the techniques that prevent medical errors are available to all the healthcare professionals (regardless of whether they provide patient care directly, or are involved in the management of the healthcare settings where the patient care is delivered). We re-affirm the commitment of the state boards of nursing to the safety of nursing care for the public’s benefit. Preface Key Points Related to Patient Safety Boards of nursing ensure competent practitioners by enforcing nursing practice regulations. Collectively, many boards of nursing have data regarding practice breakdown, including medication errors, and have been able to identify factors that contribute to errors, explore alternative approaches for responding to these factors and promote efforts to reduce the likelihood of future errors. These data have shown that most errors are caused by a complex combination of factors related to systems and practice environments as well as practitioner culpability. While the Institute of Medicine’s (IOM) report on errors in healthcare focuses on hospital organizations in its discussion of mandatory reporting and accountability, the NCSBN maintains that the perspective of individual accountability must also be considered in any efforts to implement IOM recommendations. The NCSBN understands the need to maintain confidentiality of some information to encourage reporting. It is critical, however, to ensure that regulatory boards continue to have access to information regarding errors made by nurses to determine competence for ongoing renewal of professional licenses. Both systems liability for mistakes and individual accountability is important to protect the public. Absent individual accountability standards, practitioners that leave organizations after serious errors occur and are employed elsewhere will never receive necessary remediation or education to address human factors. Core Competencies of Nursing Boards Nursing regulation is in a position to collaborate with other stakeholders to identify some of the causes of medical errors and develop strategies to help reduce them. Ongoing research of errors made by nurses has identified the factors contributing to medical errors, monitored the impact of a changing health care system on the incidence of errors, and measured the outcomes of alternative approaches to error prevention. Also, existing disciplinary action case reports related to professional competence are currently being studied to: identify elements that increase risk of errors occurring; link types of errors and root system problems; describe and correlate remedial disciplinary actions taken in relation to the types of errors identified per case; and correlate types of disciplinary action and reduction of errors to develop regulatory best practices. Nursing regulators play an important role in the prevention of medical errors. Because nursing regulators have access to all persons licensed to practice nursing, they are able to educate, inform, and disseminate information and lessons learned directly to nurses. Regulatory boards also use data to educate and inform consumers and legislators to provide additional safeguards that reduce patient risk. Multiprofessional Leadership Required To reduce the number of medical errors and improve patient safety in this country, all stakeholders must work together in a concerted effort to examine the whole of the problem. A national focus calls for leadership and research that will provide data needed to establish standards and safety expectations. Such a multifaceted approach needs to be based on collaboration between public and private sectors of health. The recommended research agenda should include evaluation of the drivers of errors, identification of the underlying factors or "root causes," and approaches for error prevention. The NCSBN is prepared to contribute to this crucial national initiative through research, data collection and sharing, advocacy and partnerships with all stakeholders. Research Focus Areas
Recommendations 1. Promote Partnerships: Simplification of the health care workforce regulatory system and other systems which affect the education, regulation, and practice of health care practitioners to streamline regulatory structures and processes resulting in opportunities for error reduction and continuity of care through collaboration. Assessment of the complex system of regulatory boards, agencies, and departments, some of which regulate facilities while others regulate individual practitioners, some which regulate the education of practitioners and others which address the practice of a profession, is challenging. Compounding this conglomeration is the overlay of federal, state, and local authority and their laws and regulations. Yet another layer is added by the private entities, e.g., accreditation agencies and certifying bodies, which provide additional credentials and/or validation of programs and services. Examples of partnership seeking by boards of nursing can be found across the country. Some boards have formed successful partnerships with in-state groups of nurses. Other has sought out boards regulating other health professions. The NCSBN has received strong encouragement to seek out partnerships with consumer and public interest groups. Telemedicine and telecommunications has provided the impetus for the licensing community to conduct such a comprehensive analysis. Collaboration among groups to reduce duplicative efforts and, in some cases, resolve conflicts of authority and purpose must be researched and encouraged. NCSBN and its members have launched a multi-state initiative to enable states to enter into a mutual recognition model of nurse licensure. States adopting an interstate compact allows a nurse to have one license (in his or her state of residency) and practice in other states, as long as that individual acknowledges that he or she is subject to each state's practice laws and discipline. Under mutual recognition, practice across state lines would be allowed, whether physical or electronic, unless the nurse is under discipline or a monitoring agreement that restricts practice across state lines. In order to achieve mutual recognition, each state would have to enter into an interstate compact that allows nurses to practice in more than one state. Like the purpose of the QuIC group today, each state agency needs to identify the core functions and ask the questions:
2. States should research the use of standardized and understandable language for all health profession regulation and their functions for error identification and reporting. Consistent definition of terms involving categories of errors, types of violations and board actions would be beneficial to health care providers and consumers. In addition to promoting consumers' understanding regarding the level of protection offered by different professional credentials, communication and coordination between boards would be enhanced. It is imperative that state boards of all disciplines communicate together on issues related to patient safety (errors), disciplinary action and remediation. Several boards of nursing have been or are currently involved in state-level efforts to standardize language (e.g., Montana, Utah and Texas). The NCSBN is developing a lexicon of disciplinary terms (and their equivalents from state to state). These efforts represent useful starting points for broader standardization of regulatory language. Any body convened to "codify regulatory terms and language" must reflect the major stakeholders impacted by the language, including the public, regulated health professions, providers and payers of health care, regulators and legislators. 3. Promoting continued competence across all health professions can reduce medical errors. Assessments for all health professions should be enhanced. States should promote the boards to develop, implement and evaluate continuing competency requirements to assure the continuing competence of all regulated health care professionals. The definitions of competence and competence assessment are crucial to this discussion. NCSBN has a working definition for competence: the application of knowledge and the interpersonal, decision-making and psychomotor skills expected for the practice role, within the context of public health, safety and welfare. Competence assessment should not be limited to an examination to measure sample knowledge and skills. Other means of competence assessment that consider application of knowledge and skills are desirable. Licensing boards are charged to maintain the balance between the rights of the professional to practice a chosen profession and the board's responsibility to protect the public health, safety and welfare. Often, the professional roles with the most ambiguities and inconsistencies are in the process of evolution and need to be closely critiqued and guided in their development. Boards serve as the advocate for the public in this process. Boards of nursing have had in place since 1979 national standardized licensure examinations. Alternative pathways in education, previous experience and a combination of education and experience should only be considered when appropriate safeguards are in place to assure competence. Entry-into-practice standards should continue to address affective and psychomotor aspects of competence as well as cognitive elements. 4. Multi-disciplinary collaboration will be necessary to establish a clear, rational model of practice across all health professions for increased patient access and safety. States should explore pathways to allow all professionals to provide services to the fullest extent of their current training, experience and skills. Collaboration between health-related boards needs to be promoted to assure sharing of critical information, coordination of efforts and timely board actions. Boards that shared information regarding licensed health professionals involved in the same of similar health care error would add depth and credibility to their oversight functions. Periodic interdisciplinary meetings among boards to discuss issues of common concern have been implemented in some states (e.g., Texas and Minnesota), and provide opportunities for collaboration and cooperation without adding another layer of bureaucracy. Joint statements and guidelines have been useful for the various professions. On a national level, the NCSBN has facilitated the convening of an Interprofessional Workgroup, composed of 15 health professions. This group has interacted regarding multiple common issues. Information sharing about similarities and differences in regulatory processes has already occurred, and it is anticipated that collaboration will continue in areas such as continued competence assessment tools, practice issues related to telecommunications, and the identification of regulatory outcomes. It is equally important for practice acts to give notice to licensees as to what is unsafe and incompetent practice. The authority and tools to effectively identify and remove unsafe, incompetent practitioners from practice and/or assist them toward rehabilitation in their practice are critical elements in the regulatory scheme and protection of the public by prevention of medical errors. Health care professions do overlap. There are many health-related functions that can be (and in many cases are) performed safely by multiple types of practitioners. Scopes of practice should not be defined as exclusive territory, but rather as delineating the boundaries appropriate for the education and experience of the category of regulated professionals. The challenge here is to articulate regulatory language that is broad enough to reflect the capabilities, breadth and evolution of practice while being specific enough to be meaningful and useful. This is why practice acts must be periodically reviewed and revised to reflect changing knowledge and technologies. But, solely performing delegated tasks does not prepare an individual for the transition to another role. Who would be responsible to track individually expanded scopes of practice? Clearly, it is to the benefit of all to facilitate professional growth, development and role transition. But, it should be done within the boundaries of articulated scopes of practice and meeting requirements for other professions. The activity of unlicensed assistive personnel is another concern of boards because their use impacts the public and their safety. Since the nature of their work is assistive, the operative principles for safe utilization of these individuals involve appropriate and responsible delegation and supervision by licensed personnel. The licensed person, who has the authority to practice the profession, is accountable for identifying the conditions for safe delegations:
Issues related to delegation have become more complex in today's evolving health care environment. Nurses, who are uniquely qualified for promoting the health of the whole person by virtue of their education and experience, must be actively involved in providing the assessment, evaluation and judgment needed to coordinate and supervise nursing care. Unlicensed assistive personnel cannot be transformed into professionals through delegation. 5. A fair, cost-effective and uniform disciplinary process to exclude incompetent practitioners will assist in the protection and promotion of the public's health. All regulatory boards must strive to attain an appropriate balance between formal administrative hearings and informal settlement methods. Due-process procedures are provided in formal and informal resolutions of discipline cases. Formal hearings may be the result of the complexity of issues, or the inability to come to resolution. Informal processes provide cost-effective and expeditious means of resolving disciplinary matters and enable boards to deal with cases in a more timely manner while still taking action, often stringent, as needed for public protection. The use of alternative-to-discipline programs (i.e., ADR) is becoming increasingly common, though there is significant ongoing debate about how best to handle confidentiality issues and fulfill the boards' responsibilities to the public. Boards of nursing spend a great deal of time and resources investigating complaints regarding licensed individuals. Individual boards have developed systems of prioritization based on consumer safety criteria and alternative mechanisms for resolution of cases, which reduce the administrative and/or punitive burdens of discipline without compromising the safety of consumers. The NCSBN has developed resources to support more effective and efficient discipline, including an empirical study of various approaches to managing nurses with chemical impairment and a training course for nursing investigators. Nursing boards are ready and willing to continue to participate in efforts to promote the visibility and recognition of boards as fair and objective forums to resolve complaints regarding professional practice. But, boards must also be prepared to handle effectively the additional complaints that such efforts generate. The matter of public access to disciplinary data is another area in which diverse state laws addressing due process, confidentiality and freedom of information create inconsistencies regarding the timing of information release and the nature of information that can be shared. The NCSBN has maintained a Disciplinary Data Bank (DDB) for more than 15 years, which is recognized as an essential research tool in sharing information about licensed nurse disciplinary actions. Closing On behalf of myself (Joey Ridenour, President of the Board) and the Executive Director, Eloise Cathcart, MSN, RN; Associate Executive Director, Donna Nowakowski, MSN, RN; NCSBN staff; Board of Directors; Committee members and volunteers—we thank the QuIC for this opportunity and pledge our support and assistance to the panel developing the group’s prioritized research agenda on prevention of medical errors and the promotion of patient safety. Current as of September 2000 Internet Citation: National Council of State Boards of Nursing, Inc.. Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/ancsbn.htm Return to Additional Statement Directory |