NUR 4327 – Deliverable 6 – TERCAP Proposal

NUR 4327 – Deliverable 6 – TERCAP Proposal

Summary of completed TERCAP report

A patient, aged 54, was 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 additional six weeks of physical therapy.

A review of the case determined that her assigned nurse on the night shift was an RN (age 24) with nine months of experience in this unit. This was her third 12-hour 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 received the bedside shift report at 7 pm and noted that the patient was 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 were very busy with patients, so this statement could not be substantiated.

The risk manager found that the RN had not followed the nursing policy for patient assessment 20 minutes after receiving pain medication and had not done the recommended hourly rounding on the patient to assess 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.

NUR 4327 – Deliverable 6 – TERCAP Proposal

Part Two – Factors and Actions

Table 1. Discuss the factors that contributed to the event and how these factors could be addressed to minimize legal risks in the table below.

Situational factors	Nursing factors	Human factors	Organizational factors
Factor #1: The patient was on post-operative day one, so risks were higher for falls.   How do you minimize legal risk? Determine the patient’s fall risk upon admission and perform a walk safety test. Determining if the patient can safely walk 10 feet on their own can aid in determining the risk for a fall postoperatively (Gregory, 2017).	Factor #1: Newer nurse with only nine months of experience.   How do you minimize legal risk? Follow facility policy and procedure. If pain medication assessments are required, they should be completed in the suggested time frame to minimize legal risk (Palatnik, 2017).	Factor #1: The nurse is 29 weeks pregnant.   How do you minimize legal risk? Pregnancy can be exhausting, especially in the latter weeks of pregnancy. Pregnant nurses, especially those with difficult pregnancies, should be in contact with HR to find reasonable accommodations for their work environment, such as not working three shifts in a row (Chang et al., 2021).	Factor #1: The facility has a high turnover rate, so it is possible that the outgoing nurse or the oncoming nurse does not know the facility’s rounding policy, especially after administering pain medication.   How do you minimize legal risk? Improving orientation can greatly impact staff satisfaction, thus decreasing nurse turnover rates (Lockhart, 2020).
Factor #2: The patient fell after the administration of pain medication. How do you minimize legal risk? Patients may experience dizziness, grogginess, or hypotension after administering pain medication. Performing proper post-pain medication assessments, including vital signs, can determine if the patient can walk safely and if the medication is acting therapeutically (Farrell, Ingar, and Shamji, 2018).   Factor #3: The patient states she was not advised to call for assistance getting up, the oncoming nurse did not repeat instructions, and the evidence could not be substantiated.   How do you minimize legal risk? Repeat instructions as the oncoming nurse and ensure the patient knows how to utilize the call bell. Assess the patient to determine the risk of falling, especially being freshly postoperative (Farrell, Ingar, and Shamji, 2018).	Factor #2: Fourteen patients per RN; 28 patients on the floor for two RNs.   How do you minimize legal risk? While most states do not mandate safe staffing ratios, nurses assigned high patient ratios can utilize extra vigilance based on assigned ratios and prioritize tasks throughout the shift to minimize errors (Bakerjian and Phillips, 2021).   Factor #3: Rounds and pain assessment were not done in the allotted time.   How do you minimize legal risk? Purposeful hourly rounding and timely pain assessments have reduced fall risks among postoperative patients (Bell, 2020). If patients are rounded on hourly, their risk for falling reduces drastically as their needs are typically met within that hourly round.	Factor #2: It is the nurse’s third 12-hour shift in a row.   How do you minimize legal risk? Ensure nurses have the resources necessary to perform well on long shifts and encourage them to write things down and double-check their work. Writing important notes and double-checking work can reduce medical errors immensely (Chang et al., 2021). Factor #3: The nurse is newer to the profession, on her 3rd 12-hour shift, and pregnant. The nurse is likely stressed and might make menial errors due to work-related stress. How do you minimize legal risk? Have the nurse take adequate breaks throughout the night and offer to split her schedule up to give time off in between shifts (Chang et al., 2021)	Factor #2: The organization has a high number of new graduate nurses and few seasoned nurses.   How do you minimize legal risk? While new graduates are invaluable team members, seasoned nurses should also be integrated into the team. Seasoned nurses can be a resource for newer nurses and aid in minimizing legal risk (Lockhart, 2020). Factor #3: Vacancies and call-ins have been an issue at the facility. How do you minimize legal risk? Have backup teams in place for call-ins; place nurses on call if there happens to be a call-in for that shift (Lockhart, 2020).

Table 2. Explain whether the nurse was negligent or whether her actions reached the level of malpractice and support your reasoning with research.

Do you believe the nurse was negligent?

Do you believe the nurse committed malpractice?

The nurse would be considered negligent. She did not confirm that the patient knew to ask for assistance when getting up, she did not round as she should have, and she did not check on the patient after administering morphine, which is known to cause drowsiness. Furthermore, she did not educate the patient on why she needed assistance walking to the bathroom one-day post-operation. Because of the nurse’s inaction, she would be considered negligent and would be held liable for the fall.

The nurse has reached malpractice. Malpractice is defined as a deviation from the standard of care in which an act of negligence or omission causes injury or harm (ABPLA, n.d.). The American Board of Professional Liability Attorneys lists improper follow-up or aftercare as an example of medical malpractice, which occurred in the patient’s case (ABPLA, n.d.). Because the nurse was negligent in giving proper education regarding the need for assistance with ambulation and follow-up after she administered the pain medication, and the patient fell and sustained injuries, as a result, it would be considered malpractice.

Table 3. Determines what options the nursing board had regarding this nurse’s license to practice nursing.

Nursing Board Options		Supporting details with reference
Option 1: Fine or civil penalty.		The Board of Nursing may impose a fine or civil penalty depending on if the patient files a lawsuit. Because the patient needed further hospitalization and rehabilitation after the fall, it is likely that the nurse will have to pay a fine or civil penalty (NSCBN, n.d.)
Option 2: Monitoring, remediation, or education tailored to the situation.		The nurse may need to receive additional education on patient education, hourly rounding, and post-pain medication assessment. The nurse must be monitored to ensure that no other patient falls happen while the patient is in her care (NCSBN, n.d.).
Option 3: Separation from practice for some time or loss of license.		Depending on the severity of the patient’s injuries, the nurse may face suspension or revocation of her license. If the nurse is suspended, the board may couple her suspension with education and/or fines (NSCBN, n.d.).

Table 4. Describe your reasoning for what action you would recommend (warning, probation, revocation of license) if you were on the disciplinary committee of your Board of Nursing.

Recommended Action

Description to support your recommendation

I would recommend a 90-day suspension of the license, further education, and monitoring for one year.

The nurse had external factors that were out of her control during her shift, like staffing issues, so I do not think revocation is the correct action. However, it is still the nurse’s responsibility to ensure the safety of her patients while they are in her care, so suspension is appropriate. Additionally, she should take educational courses on falls, the importance of rounding, patient education, pain medication administration, and the importance of assessments after medication administration. She should be monitored to ensure no more falls occur under her care, patients remain safe, and post-pain medication assessments are completed within the facility’s allotted time frame (NCSBN, n.d.). If another negligence or malpractice case is found, revocation of the nurse’s license should occur.

Table 5. Explain how the nursing behavior level relates to your proposed recommendation on licensure.

The nurse caring for the patient had many factors relating to her nursing behavior that led to the sentinel event, including being recently graduated, short staffing, and (most likely) fatigue related to her pregnancy and how many shifts she worked in a row. However, she had behaviors that were well within her control. The nurse should have woken the patient to advise her to ask for assistance when getting out of bed rather than assuming she knew, and she should have checked in with her at least every hour and after administering the pain medication. This case is outright negligence if not malpractice. Furthermore, because the patient sustained serious injuries and needed further hospitalization due to the nurse’s inaction, the offense is much worse. A warning would be indicated had she woken up her patient to inform her of the need for assistance with ambulation and had she been rounding hourly. However, because she failed to do so, suspension is indicated. Revocation, however, is not indicated because it is her first offense. If another similar event occurs, the nurse would then be considered for revocation. Nurses have a duty to act professionally and safely for the sake of their patient’s health and safety; therefore, they breached the standard of care required by the Board of Nursing (NCSBN, n.d.). Further education and close monitoring once her license is reinstated is necessary.

Tip: You want to base your recommendations based on the nursing board’s interpretation of findings. For example, suppose you find the nurse in the scenario negligent. In that case, this should be supported by behaviors within the scenario and align with the nursing board’s interpretation of negligence.

Again, be sure to support your recommendations with references from the literature (start your search by looking at articles of negligence).

Part Three – Continuing Education

Please provide a summary of the topics to be provided to the education department based on the summary of the TERCAP report.

• Safe medication administration (Texas Board of Nursing, d.)
  • The nurse administered the correct dose via the right route but failed to reassess the patient after administering the medication.
• Attentiveness/Surveillance (Texas Board of Nursing, d.)
  • The nurse failed to monitor what was happening with the patient. She did not notice that the patient needed to use the bathroom and failed to realize she had gotten out of
• Prevention (Texas Board of Nursing, d.)
  • The nurse failed to follow customary measures to prevent the risk of falling, and the patient suffered major injuries following the

• Professional Responsibility (Texas Board of Nursing, d.)
  • The nurse failed to act responsibly in educating the patient on the need to have assistance ambulating post-operation and did not round properly, especially after administering pain.

References

American Board of Professional Liability Attorneys. (n.d.). What is medical malpractice?
https://www.abpla.org/what-is-malpractice

Bakerjian, D., and Phillips, J. (2021). Nursing and patient safety. https://psnet.ahrq.gov/primer/nursingand-patient-safety

Bell, I. (2020). Purposeful hourly rounding and reduction of patient falls.
https://digitalcommons.jsu.edu/cgi/viewcontent.cgi?article=1001&context=etds_nursing

Chang, H., et al. (2021). Nurses’ Clinical Work Experience During Pregnancy. Healthcare, 9(1), 16.
https://doi.org/10.3390/healthcare9010016

Farrell, B., Ingar, N., and Shamji, S. (2018). Reducing Fall Risk While Managing Hypotension, Pain, and Poor Sleep in an 83-Year-Old Woman. Canadian family physician, 59(12), 1300-1305.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860927/
Gregory, B. (2017). 4 keys to prevent patient falls. https://www.aorn.org/outpatientsurgery/articles/outpatient-surgery-magazine/2017/december/4-keys-to-prevent-patient-falls

Lockhart, L. (2020). Strategies to Reduce Nursing Turnover. Nursing made incredibly easy, 18(2), 56.
https://doi.org/10.1097/01.NME.0000635196.16629.2e

NCSBN. (n.d.). Board action. https://www.ncsbn.org/nursing-regulation/discipline/board-action.page
NCSBN. (n.d.). Discipline. https://www.ncsbn.org/nursing-regulation/discipline.page

Palatnik, A. (2017). Reducing Your Liability Risk. Nursing critical care, 7(4), 4.
https://doi.org/10.1097/01.CCN.0000415614.89752.cc

Texas Board of Nursing. (n.d.). A method to determine factors associated with nursing practice
breakdown. https://www.bon.texas.gov/practice_TERCAP.asp.html

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NUR 4327 – Deliverable 6 – TERCAP Proposal

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 on your recommendations.

Instructions

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

Part One – Review the summary of the completed TERCAP report below.

A patient, aged 54, was 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 additional six weeks of physical therapy.

A review of the case determined that her assigned nurse on the night shift was an RN (age 24) with nine months of experience in this unit. This was her third 12-hour shift in a row, and she was 29 weeks pregnant. There were 28 beds 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 many 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 received the bedside shift report at 7 pm and noted that the patient was 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 said 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 were very busy with patients, so this statement could not be substantiated.

The risk manager found that the RN had not followed the nursing policy for patient assessment 20 minutes after receiving pain medication and had not done the recommended hourly rounding on the patient to assess 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 the 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 whether her actions reached 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.
• Describe your reasoning for what action you would recommend (warning, probation, revocation of license) if you were on the disciplinary committee of your Board of Nursing.
• Explain how the nursing behavior level 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.