2010 News

Medication and medical errors: how BORN is handling complaints

04.19.2010

From the Massachusetts Nurse Newsletter
April 2010 Edition

By Mary Crotty
Associate Director, Nursing

Disciplinary actions brought against nurses are discussed at BORN’s monthly meetings, along with other BORN business. Over the past two years, MNA staff have noticed a change — for the better — in the attitude toward resolution of complaints against nurses by BORN board members, primarily in resolving complaints related to single med errors. There are a few board members who are out of touch clinically, or out of touch with current patient safety research and literature, who are still punitive in their approaches but increasingly they are outvoted.

Some, but not all, new BORN appointees are clearly much more knowledgeable about the current drive to improve patient safety and reduce errors by adopting “just culture” approaches toward med errors.

It is important for bedside nurses to be aware of this change at BORN. Despite an apparent increase in harassment recently from nurse managers (i.e., threats to report nurses to BORN for incidents of minor infractions or errors) the reality is that BORN has pretty much been dismissing complaints of single med errors for the last two years.

This enlightened approach has arrived slowly but it is being demonstrated fairly consistently in BORN disciplinary decisions. The change for the better is being driven by extensive research by patient safety and patient advocacy organizations and by research done by BORN staff. The most significant findings that are used by BORN and others to support a less punitive approach toward resolving complaints which often stem from system problems are outlined in the resource list included below.

For nurses who feel harassed or threatened with “BORN,” the information below might be useful to share with their managers. Web site links with further information are also listed below.

Despite the less punitive atmosphere, be sure to renew or obtain your own liability insurance (NSO is the MNA’s preferred provider). NSO will provide nursing license protection— that is, they will pay an attorney to represent you before the board, no matter the reason. If you are caught in a situation where you must respond to the BORN, having your own liability insurance will be invaluable.

Note: MNA staff and board members attend monthly meetings of the BORN as observers. BORN meetings are held the second Wednesday of every month. Visitors are welcome. Contact Mary Crotty for more information at 781.830.5743 or via e-mail at mcrotty@mnarn.org if you would like to attend or if you have questions related to this topic. Nurses who drop in on BORN meetings find they can be quite enlightening.

 

Resource List

Mass. Board of Registration in Pharmacy

The Massachusetts Board of Pharmacy has developed “Best Practices Recommendations to Reduce Medication Errors:” Its top recommendation: “Promote a non-punitive atmosphere for reporting medication errors.”

Massachusetts Coalition for the Prevention of Medical Errors

The Mass. Coalition for the Prevention of Medical Errors is nationally known for its exploration of the causes of medical errors.

The coalition recommends two basic principles that make up the foundation of their best practice recommendations:

Adopting a systems-oriented approach to medication error reduction. Recent studies have indicated that errors, while made by individuals, are often the result of error-prone systems, processes and tasks.

Promoting a non-punitive atmosphere for reporting errors which values the sharing of information about the causes of errors and strategies for prevention. Other industries, such as aviation, have moved away from an atmosphere of blame and punishment to one of system redesign. The best approach to prevention is one that encourages learning from mistakes. To do this, people must be able to talk about errors in a safe environment. Health care leaders must continue to hold care givers accountable for professional judgment while at the same time work to make processes for delivering care as error proof as possible.

Institute for Healthcare Improvement

The Institute for Healthcare Improvement is an independent non-profit organization based in Cambridge with nationally recognized principals (Lucian Leape, Don Berwick and Jim Conway) who work as specialists in health care improvement throughout the world. Founded in 1991 the IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. One of its primary focuses is building a “culture of safety.” A leading strategy of IHI is to promote a non-punitive approach to medication errors.

Institute for Safe Medication Practices

ISMP is a federally certified patient safety organization that promotes and awards recognition to providers who work to develop safe patient practice environments. It advocates for the creation of non-punitive environments where error reporting is encouraged in order to best address what it has determined is largely a problem driven by system or environmental practices.

The Joint Commission

The Joint Commission calls for the creation of a “culture of safety.” It stresses that organizations should have a “transparent and equitable disciplinary process that takes into account personal responsibility and accountability.”

It notes two major actions that erode leadership credibility and undermine organizational safety culture:

Terminating or failing to support an employee who committed a blameless act during the course of an adverse event.

Exempting influential individuals from complying with organizational quality and safety policies, such as policies on intimidating and disruptive behaviors.

TJC states, “The inconsistent application of such policies are noticed by staff and are correctly interpreted as only paying lip service to safety.”

Massachusetts Nurse Practice Act

The Massachusetts Nurse Practice Act’s Standards of Conduct provides the basis for holding nurse managers liable for practicing in accordance with “accepted standards of practice.”

The in-state standard pertaining to BORN’s duty to discipline nurse managers reads:

A nurse licensed by the Board and employed in a nursing management role shall adhere to accepted standards of practice for that role. The responsibilities of the nurse employed in a nursing management role are to develop and implement the necessary measures to promote and manage the delivery of safe nursing care in accordance with accepted standards of nursing practice.

FPO