During Phase I, which builds on findings from the Massachusetts Coalition for the Prevention of Medical Errors' Accountability Project, the project team will form a strategic alliance of state and federal regulatory agencies and industry stakeholders, and develop a systematic plan for the design, implementation and evaluation of a facility-based Nurse-Employer Safety Partnership (NESP) pilot. To achieve these goals, the project team will undertake three major activities:
- Conduct an environmental scan involving nurses practicing in randomly-selected nursing homes in order to anonymously determine their perceptions of their facility's culture of safety and barriers to medication error reporting;
- Create a high quality sustainable strategic alliance of state and federal regulatory agencies, directors of nursing and industry stakeholders, using an evidence-based strategy, to inform and assure alignment of the reporting of medication errors and near misses by Massachusetts nursing homes with the reporting requirements established by state regulatory agencies;
- Develop and implement a systematic plan, using data from the environmental scan, for the design, pilot implementation and evaluation of:
- a "culture of safety" curriculum for delivery to directors of nursing and others in nursing service leadership within participating nursing homes;
- an education-oriented NESP model which will assign responsibility at the facility level for conducting a root cause analysis of medication errors and near misses that meet Board-approved criteria, and implementing a corrective action plan for practice remediation and systems change;
- an NESP "Safety Culture Tool Kit for Reporting Medication Errors and Near Misses" for use by directors of nursing and others in nursing service leadership within participating nursing homes; and
- a multi-level learning network for lessons learned.
Implemented in its entirety over a four year time frame, this patient safety initiative differs significantly from alternative discipline programs already established by other boards of nursing. The Board will assign responsibility at the facility level for addressing medication errors and near misses that meet Board approved criteria and foster facility-based error recognition, disclosure and systems improvement.
When completed, the initiative's deliverables are to:
- Cultivate a regulatory environment in which nurses' fear of disciplinary action in response to medication error or near miss is reduced or dispelled.
- Encourage and support a culture of safety within participating nursing homes.
- Foster remediation of the nurse's practice and systems change through the NESP model involving analysis of both the human performance and systems factors associated with the nurse's medication error or near miss.
- Contribute to safe medication administration practices among nurses practicing in nursing homes statewide through the sharing of lessons learned, implementation processes and best practices resulting via an NESP information network.
- Establish a quality and sustainable strategic alliance between policy makers and practitioners that is capable of proactively responding to future challenges and opportunities related to patient safety and care.
This information is provided by the Division of Health Professions Licensure within the Department of Public Health.