Employer Complaint
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Should I Report?

The Board evaluates all complaints to ensure public protection. All allegations are evaluated with respect to jurisdiction, risk to the public and the circumstances leading to the reported incident/event.

N.C.G.S. (North Carolina General Statute) § 90-171.47

Complaint Gateway

Definitely Reportable Conduct Events

  • Fraud
  • Theft
  • Sexual Misconduct
  • Mental/Physical Impairment
  • Inappropriate Prescribing
  • Criminal Charges/Convictions
  • Drug Abuse
  • Impairment on Duty
  • Drug Diversion
  • Positive Drug Screen
  • Fraudulent Prescription for Controlled or Abusable Substances

The Board recognizes that minor deficits in practice or behavior may be appropriately addressed at the employment level. Minor deficits are those where the potential risks to the patient are very low, the incident is a one time occurrence with no pattern of poor practice, the nurse is accountable for her/his practice and the nurse appears to have knowledge and skills to practice safely.

Potential Reportable Events

  • Abandonment
  • Breach of Confidentiality
  • Inappropriate Delegation and/or Assignment
  • Failure to Maintain Accurate Documentation
  • Exceeding Scope of Practice
  • Failure to Maintain Standards of Care
  • Failure to Supervise
  • Inappropriate Interaction with Client (Verbal/Physical)
  • Neglect - Includes Sleeping on Duty
  • Failure to Report Crucial Healthcare Information

The North Carolina Board of Nursing Complaint Evaluation Tool (CET) will assist you in determining the report-ability of these events.

Common Non-Reportable Events

(List is not all inclusive of non-reportable events)

  • No Call-No Show
  • Failure to Complete a Resignation Notice or Abrupt Termination
  • Refusal to Accept an Assignment
  • Rudeness or Non-threatening Verbal Interactions with Patient or Staff
  • "Nodding" or momentary unintentional falling asleep, unless this is a pattern of behavior, or results in patient neglect or risk
  • Falsification of Employment Application (except when falsification relates to licensure status)
  • Failure to Follow Agency Policy (unless there is ALSO a violation of the Nursing Practice Act)
  • Information related to mental or physical conditions of a nurse, obtained while providing care for the nurse (protected information)
  • Systems Issues, including but not limited to:
    • Malfunctioning Equipment
    • Staffing/Work Hour Issues
    • Physician/Nurse Communication Barriers
    • Outdated Policies/Procedures (does not reflect current evidence based practice)
    • Inappropriate Assignment Practices

Event Investigation Guide

Use the reliable How? When? Where? Who? What? and Why? questions in a consistent manner to assure that you have examined all elements of and influences on the event.

Answer and document all of the following questions concerning the event in question:

HOW was the event identified or discovered?
WHEN was the event identified or discovered?
  • When did the event happen? – At what time?
WHERE did the event occur?
  • Describe location and any unusual elements of the environment and location.
WHO has direct knowledge of the event?
  • Who discovered or identified the event and how did they do so? – How did the event come to their attention?
  • Who reported the event and how did they do so? – How did the event come to their attention?
  • Who was directly involved in the event?
    • Nurse(s)
    • Physicians
    • Other Staff (e.g., Nurse Aides, Therapists, Secretaries) 
    • Client(s)
    • Family Members/Visitors
  • How were each of the individuals involved in the event ? What role did they play in the event?
  • Interview nurse(s) and other involved staff (each separately) as soon as possible after the event
    • Start by using open-ended questions and allowing involved staff to tell their stories about what happened; • What rationale did they offer for their behavioral choices?
    • What was their perception of risk ?
    • Did they acknowledge and accept responsibility for event fully or partially?
    • Were they previously formally counseled (i.e., documented and signed) for same or similar issues?
    • Were they experienced and oriented to this unit, patient type, etc.?
  • Interview witnesses (each separately) as soon as possible after event:
    • Start by using open-ended questions and allowing direct witnesses to tell their stories about what happened;
    • Consider degree of agreement or disagreement among witness statements;
    • Consider facts and what was actually observed by individuals – do not consider opinions not supported by evidence and corroborating statements.
WHAT happened?
  • Describe the actual event in detail;
  • Reconstruct the sequence of events;
  • Remember to consider preceding activities that may have impacted the event.
  • What usually happens in similar situations? – Describe what involved staff and non-involved staff tell you about such situations – what is their “normal”, current practice? (Make sure they are not just telling you what you want to hear or what policy says!)
  • What should have happened? – describe related policies and procedures. (When actual practice varies from policy, you will want to explore why and address this with all staff – maybe policy is out of date or impossible to follow – or maybe all staff have drifted from safe practice!)
WHY did the event occur?
  • Identify any and all factors contributing to the event.
  • What behavioral choices related to the event did each involved nurse or individual make before, during, and following the event?
  • What behavioral choices would a similarly prepared and experienced prudent nurse (or other involved person) have made in the same situation?
  • If individual(s) deviated from standards, policies, or procedures, identify rationale for decision to deviate.
  • What was happening with other clients and in the environment at the time of the event and immediately prior to the time of the event?
  • What was the nurse to client ratio at the time of the event? – Was this a safe, acceptable, manageable ratio?
  • Describe any variable factors, such as busy unit, staff call-outs, etc., that influenced workload at the time of the event.
  • Was this the usual assignment/unit for the nurse(s) involved in the event? 
  • What equipment/supplies were involved in the event ? – describe equipment/supplies and any unusual aspects, malfunctions, availability issues, etc.
COLLECT AND PROTECT all physical evidence:
  • Documentation and records
  • Audit current and past records, if indicted, to identify documentation discrepancies, deficits, and omissions; 
  • Supplies, equipment, medications, etc.
SUMMARIZE AND DOCUMENT investigation results and conclusions:
  • Identify all system issues that need to be corrected.
  • Identify all individual practice issues that need to be addressed.
  • Identify all known contributing/mitigating/aggravating factors – system and individual

Complaint Gateway

Just Culture Overview

General Information

The Board has made concerted efforts to move from the traditional regulatory culture of blame and shame to a culture of quality improvement and patient safety. All complaints are taken very seriously. All allegations are evaluated with respect to the merits of the individual case and actual or potential risk to the public as a result of the individual nurses’ behavioral choices. The Board can only take formal action if there is clear and convincing evidence that the nurse violated state nursing laws or rules.

The Board has adopted a “Just Culture” which promotes a learning culture that supports patient safety while assigning accountability for behavioral choices. The Board uses “Just Culture” concepts when reviewing practice events or errors and when identifying appropriate resolutions that promote practice enhancement and patient safety.

The Complaint Evaluation Tool (CET) was developed by the Board of Nursing to identify and clarify when practice events require a report to the Board. The Complaint Evaluation Tool serves as a framework through which employers, nursing leaders, and the Board of Nursing can evaluate and analyze practice events or errors with consistency and fairness. The Complaint Evaluation Tool is designed for use only when evaluating clinical practice events or issues involving nurses.

Use of the Complaint Evalution Tool and consultation with Board staff guide the employer and nurse leaders to evaluate whether the practice event/issue was the result of human error, at-risk behavior, or reckless behavior, and further determines whether the behavioral choices warrant consoling, counseling, remediation, or discipline.

More About Just Culture

Concepts and Definitions

Concepts

  • Focus on evaluating the behavioral choices made by an individual, not on the outcome of the event; 
  • Require leadership commitment and modeling; 
  • Distinguish among normal human error, unintentional risk-taking behavior, intentional risk-taking behavior, and reckless behavior; 
  • Foster a learning environment that encourages reporting (including self-reports) of all near misses, mistakes, errors, adverse events, and system weaknesses; 
  • Lends itself to continuous improvement of work processes and systems to ensure the highest level of client and staff safety; 
  • Encourage the use of non-disciplinary actions whenever appropriate (including coaching, counseling, training, and education); 
  • Hold individuals accountable for their own performance in accordance with their job responsibilities; and, 
  • Does not expect individuals to assume accountability for system flaws over which they had no control.

Terms, Definitions and Examples

Human Error (Not reportable to Board of Nursing)

Definition:

  • Nurse inadvertently, unintentionally did something other than intended or other than what should have been done; 
  • A slip; 
  • A lapse; or 
  • An honest mistake. 
  • Isolated event, not a pattern of behavior.

(Repetitive human error or pattern of behavior requires further evaluation)

Examples:

  • Single medication event/error (wrong dose, wrong route, wrong patient, or wrong time) 
  • Failure to implement a treatment order due to oversight 

Responses to Behavior:

  • Consoling or Coaching

At-Risk Behavior

(Board of Nursing Practice Consultant to be contacted for consultation)

Definition:

  • Behavioral choice that increases risk where risk may not be recognized or is mistakenly believed to be justified; 
  • Nurse does not appreciate risk; 
  • Unintentional risk taking; and 
  • Nurse’s performance or conduct does not pose a continuing practice risk to clients or others. 

(Repetitive at-risk behavior or pattern of behavior requires further evaluation)

Examples:

  • Exceeding scope of practice 
  • Pre-documentation 
  • Minor deviations from established procedure 
  • Nurse knowingly deviates from a standard due to a lack of understanding of risk to client, organization, self, or others

Responses to Behavior:

Coaching or Counseling

  • If behavior not a pattern of practice) to raise awareness of accepted procedures and potential risks for failure to comply 
  • Remedial actions taken may include education, training, and assignment of activities appropriate to knowledge and skill 
  • Nurse may be informed failure to change is not an option 
  • If nurse does not accept coaching, may result in disciplinary action

Board Action:

  • Non-disciplinary Remediation 
  • Disciplinary Action if Indicated

Reckless Behavior

(Mandatory report to Board or Nursing required)

Definition:

  • Nurse consciously disregards a substantial and unjustifiable risk; 
  • Nurse's action or inaction is intentional and purposeful; or 
  • Nurse puts own self/personal interest above that of client, organization or others

Examples:

  • Nurse abandons patients by leaving workplace before reporting to another appropriately licensed nurse. Nurse leaves workplace before completing all assigned patient/client care (including documentation) for a non-urgent reason. 
  • Nurse does not intervene to protect a patient because nurse is not assigned to patient 
  • Nurse makes serious medication error, when realized tells no one, and when questioned denies any knowledge of reason for change in client condition 
  • Nurse falsifies documentation to conceal an error

Response to Behavior:

  • Report to Board for Investigation 
  • Disciplinary Action by Board

Additional Definitions

Consoling – affording comfort or solace; restoring confidence and relieving anxiety.

Coaching – supportive discussion with an employee on the need to engage in safe behavioral choices.

Counseling – a first step in disciplinary action; putting an employee on notice that performance is unacceptable.

Just Culture Podcasts

Introduction to Just Culture and the North Carolina Board of Nursing Complaint Evaluation Tool

This Podcast introduces you to the basic principles of Just Culture and to the use of these concepts in evaluating the reportability of untoward events to the Board. Right-Click the link below and “Save Target As” or “Save Link As” to save the audio podcast to your computer. The MP3 audio file can be played back on any portable digital media player, most cell phones and any computer.

MP3 - Introduction to Just Culture (Audio only)

Podcast - Introduction to Just Culture (Slide presentation)

Podcast - Student Practice Event Evaluation Tool (SPEET) (Slide presentation)

Complaint Evaluation Tool (CET)

The Complaint Evaluation Tool (CET) was developed by the Board of Nursing to identify and clarify when practice events require a report to the Board. The Complaint Evaluation Tool serves as a framework through which employers, nursing leaders, and the Board of Nursing can evaluate and analyze practice events or errors with consistency and fairness. The Complaint Evaluation Tool is designed for use only when evaluating clinical practice events or issues involving nurses.

Student Practice Event Evaluation Tool (SPEET)

Purpose: The purpose of the “Just Culture” program is to provide a mechanism for Nursing Education Program faculty and the regulatory board to come together to develop a culture that promotes learning from student practice errors while properly assigning accountability for behaviors and consistently evaluating events.

Document Downloads

Definitions

Human Error – nurse inadvertently, unintentionally did something other than intended or other than what should have been done; a slip, a lapse, or an honest mistake. Human errors are not reportable events.

At Risk Behavior – nurse makes a behavioral choice that increases risk; mistakenly believed risk to be justified; nurse does not appreciate risk; or unintentional risk taking; At Risk Behaviors may or may not be reportable events. Consultation with an North Carolina Board of Nursing Practice Consultant assists employers and nurse leaders in determining the need for a Board report.

Reckless Behavior – nurse makes the choice to consciously disregard a substantial and unjustifiable risk. The nurse’s action or inaction is intentional and purposeful. The nurse puts own self/personal interest above that of the client, organization, or others. Reckless Behaviors require mandatory report to the Board.

Additional Resources

Last Changed 7-Aug-2020

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