Mary Beth Thomas, PhD, RN
Chair, TERCAP Committee

TERCAP Committee Members
Mary Beth Thomas (PhD. RN, Chair)
Julia George (MSN, FRE, RN, Board Liaison)
Chuck Cumiskey (MBA, BSN)
Janet Edmonds (MSN, RN)
Marney Halligan (Ed. D., RN)
J.L. Skylar Caddell (RN-BC)
Ann Ricks (MSN, RN)
Melinda Rush (DSN, FNP/ANP, RN)
Liz Faber (BSN, RN)

NCSBN TERCAP Supporting Team
Maryann Alexander , PhD, RN, Chief Officer
Nancy Spector , PhD, RN, Director
Elizabeth H. Zhong , PhD, Associate
Beth Radtke , MS, Senior coordinator
Qiana Hampton, MBA, Administrative assistant

Outline
 Purpose of TERCAP
 Key findings from the TERCAP database
 2011 TERCAP Instrument
 Future plan for the development of the TERCAP database

Purpose of TERCAP
The TERCAP (Taxonomy of Error, Root Cause
Analysis and Practice Responsibility) database is designed to collect the practice breakdown data from boards of Nursing (BONs) to identify the root causes of nursing practice breakdown from the health care system and individual perspectives. This approach will facilitate the development of strategic interventions to ensure the highest safety standards of nursing practice.

Significance of TERCAP

Milestones of TERCAP
 1999 : NCSBN appointed the Disciplinary Issues
Task Force .
 2002 : Benner, et al., “ Individual, Practice, and
System Causes of Errors in Nursing: A
Taxonomy ” was published in JONA.
 2006 : Benner , et al., “ TERCAP: Creating a
National Database on Nursing Errors ” was published in Harvard Health Policy Review.
 2007 : TECARP Online Instrument was released.

Milestones of TERCAP (con’t)
 2008 : TERCAP Online Instrument was revised.
 2008 : NCSBN hosted the TERCAP Forum in
Chicago.
 2009 : The NCSBN published an introduction book
“ Nursing Pathways for Patient Safety ”.
 2011 : The first TERCAP report was completed.
 2011
:
The 2011 TERCAP Instrument accompanied by an updated protocol was released.

Distribution of 22 Boards of Nursing
Participating in TERCAP

Case Selection
Cases meeting the following criteria are used for the analysis:
 The case involves a nurse who was involved in the practice breakdown.
 The case involves one or more identifiable patients.
 The case results in some types of board action
(disciplinary action, alternative program, nondisciplinary action, referral to other agency).

Profile of Nurses Who Committed
Practice Breakdown
 861 nurses were reported to 20 BONs for having committed practice errors.
 83% were female and 17% were male.
 The average age of the nurses was 46.2 (SD=11.6, n=834), ranging from 21 to 77.

Profile of Nurses Who Committed
Practice Breakdown (con’t)
Sixty percent of the nurses held RN licenses, 37% held LPN/VN licenses, and 3% of them held multiple licenses (RN and LPN/VN or APRN licenses, while
1% of them were advanced practice registered nurses (APRN).

Profile of Nurses Who Committed
Practice Breakdown (con’t)
2010 TERCAP Statistics and License
Statistics in 20 Jurisdictions
22%
38%
APRN
LPN/VN
RN
74%
61%
TERCAP
Statistics
(N=837)
State License
Statistics
(N=1,543,871)

Profile of Nurses Who Committed
Practice Breakdown (con’t)
Employment Setting
Employment Setting
Hospital
Long-term Care/Assisted Living
Outpatient Setting
Behavioral health
Other
% (N)
38 (331)
32 (277)
17 (147)
3 (27)
10 (79)

Profile of Nurses Who Committed
Practice Breakdown (con’t)
Length of Licensure
Years Licensed
Less than 5 years
5 to10 years
11 to 20 years
21 to 30 years
Above 30 years
Missing
% (N)
20 (171)
17 (148)
22 (191)
15 (126)
8 (72)
18 (153)

Profile of Nurses Who Committed
Practice Breakdown (con’t)
Composition of Employment History (N=725)

Employment Status
Practice Breakdown
Have you seen this nurse?
New Employment
Additional Practice Breakdown

Individual Factors Contributing to
Practice Breakdown
 55% of the nurses committed a practice breakdown when they worked in a location for two years or less, but 73% of them had been licensed for two years or longer.
 36% of these nurses were previously disciplined and 38% were terminated by their employers for practice related issues in the past.

Nature of Practice Breakdown Cases
Practice Breakdown Categories
Practice Breakdown Categories % (N)
Lack of Professional Responsibility
Lack of Clinical Reasoning
Lack of Intervention
Documentation Error
Lack of Interpretation
Medication Error
Lack of Attentiveness
Lack of Prevention
77 (665)
51 (441)
50 (434)
44 (380)
40 (343)
32 (278)
25 (219)
24 (208)

Nature of Practice Breakdown Cases (con’t)
Total Number of Practice Breakdown Categories Selected

Nature of Practice Breakdown Cases (con’t)
 72% of the cases involved unintentional human errors.
 52% of the practice breakdown cases did not cause any harm to patients.
 59% of the cases investigated resulted in disciplinary actions, and 23% of the cases were sanctioned non-disciplinary actions.

Summary
 A statistically significant link between the employment history and the risk of committing additional practice breakdown is established by the current analysis. This finding indicates that the nurses’ employment history can serve as a useful tool to identify a small group of nurses with a high risk of committing violations.
 We were not able to identify sufficient association between system factors and the practice breakdown, possibly due to constraints in sample size.

Build the Bridge
 “ Changes in health care policy requires the input and action of legislators and officials ” who need to
“have an in-depth understanding of the nursing practice” (Benner, et al., 2006).
 To influence health care and nursing policy at local, state, national, and possibly international levels, a national database on nursing practice breakdown is prerequisite.
 TERCAP will function as a national adverse events database to bridge nursing professionals with public officials and legislators.

Rationale for the 2011 Instrument Update
 To establish TERCAP as a national database on nursing practice breakdown.
 To collect more valid data to determine the impact of system factors in practice breakdown.
 To make the data entry less time consuming.
 To reduce missing records or selection of
“unknown” in data entry.

Features of the 2011 TERCAP Instrument
Streamlined
Shorter
Focused
Concise

Overview of the 2011 TERCAP Instrument
The updated instrument contains 45 mandatory and 17 optional questions
 Nurse Characteristics
 Patient Characteristics
 System Factors
 Practice Breakdown
 Optional Questions

2011 TERCAP Instrument in WORD Format

2011 TERCAP online Data Entry Screen Shot

Future Plan
 Publish the TERAP findings in 2012.
 Collect 1,000 additional practice breakdown cases by April 2012.
 Explore the impact of system factors and other unsolved research questions.

Acknowledgement

Participating BONs
Texas State Board of Nursing
North Carolina Board of Nursing
Arizona State Boards of Nurse
North Dakota State Board of Nursing
Idaho Board of Nursing
Minnesota Board of Nursing

Participating BONs
Kentucky Board of Nursing
Oklahoma Board of Nursing
Ohio Board of Nursing
Alaska Board of Nursing
Nevada Board of Nursing
New Hampshire Board of Nursing

Participating BONs
New Jersey Board of Nursing
Maine State Board of Nursing
Mississippi Board of Nursing
Virginia Board of Nursing
New Mexico Board of Nursing
West Virginia Board of Examiners for
Registered Professional Nurses

Participating BONs
Louisiana State Board of Practical Nurse
Examiners
West Virginia State Board of Examiners for
Licensed Practical Nurses.
Arkansas Board of Nursing
New York State Board of Nursing

TERCAP Contact
Elizabeth H. Zhong
E-mail: ezhong@ncsbn.org
Beth Radtke
E-mail: bradtke@ncsbn.org