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Key messages for nursing regulation from the National Patient Safety Foundation report Free from Harm: Accelerating Patient Safety Improvement.

Fifteen years after To Err is Human: Building a Safer Health System (Institute of Medicine, 1999), patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response. With a grant from American International Group, Inc., the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the gaps and review the current state of patient safety, offering detailed recommendations for continued progress in patient safety for the next 15 years. Although much advancement in patient safety has been made, the expert panel stated that efforts to enhance patient safety have "progressed at a rate much slower than anticipated". Appreciating the fact that patient safety is far more complex than originally thought, the panel emphasized these new recommendations will require involvement of all healthcare stakeholders, including boards/ governing bodies, leadership, government agencies, public-private partnerships, health care organizations, ambulatory practices and settings, researchers, professional associations, regulators, educators, the health care workforce, and patients and their families.

Additionally, because efforts in the past have focused primarily on hospitals, the panel suggested improvement efforts must be across the healthcare continuum. Patient safety must be seen as a public health issue. As the report indicates, to continue progress in patient safety and to keep patients free from harm, a commitment by all stakeholders, including nursing regulation, will be needed.

The expert panel developed eight recommendations with specific action steps, some of which may impact the regulation of healthcare and healthcare providers. These recommendations are aimed at forging a path forward in order to prioritize further improvements in the safety and quality of care. The recommendations are aimed at making fundamental, widespread improvement in patient safety and are to:

1. Ensure that leaders establish and sustain a safety culture;

2. Create centralized and coordinated oversight of patient safety;

3. Create a common set of safety metrics that reflect meaningful outcomes;

4. Increase funding for research in patient safety and implementation science;

5. Address safety across the entire care continuum;

6. Support the health care workforce;

7. Partner with patients and families for the safest care; and

8. Ensure that technology is safe and optimized to improve patient safety (NPSF, 2015).

The key messages for nursing regulation include:

* Although many improvements in patient safety have occurred, much work remains;

* Improvements need to be across the healthcare continuum;

* When investigations of violations of Board of Nursing (BON) Rules are initiated, there needs to be consideration of the safety culture of the organization that employed the nurse, including:

** Full disclosure of errors when errors occur;

** Bedside report and rounding;

** Patient involvement in root cause analysis;

** Active and engaged Peer Review Committees;

** Existence of organizational patient advisory councils; and

* Public awareness of the mission and patient safety consideration of the BON.

The eight key recommendations made by the expert panel offer an opportunity for the BON to evaluate the Board Rules, resources, and tools in consideration of current best-practices in patient safety. The crosswalk in Table 1 provides an evaluation of the Board Rules, resources, and tools that demonstrates alignment with the key recommendations made by the expert panel.

In summary, improving patient safety has become a national initiative, calling on all stakeholders, including patients and their families, to engage in ensuring a safer experience within the health care system by being an informed participant with the interdisciplinary care team. This requires continuous learning and clear communication of information among providers, organizations and patients, with the goal of promoting a safe patient care environment. Nursing regulators and nurses have a key role in improving patient safety. The BON routinely engages in the evaluation and analysis of updates and recommendations for healthcare improvement, compared to current rules and regulations for evaluation of continued pertinence and relevance, as evidenced by the NPSF recommendations and BON crosswalk. The BON remains committed to engaging in a proactive approach to nursing regulation that demonstrates integrated awareness of key environmental changes.


National Patient Safety Foundation. (2015). Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Boston: National Patient Safety Foundation.

Institute of Medicine. (1999). To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press.

The Texas Board of Nursing. (2010). Differentiated Essential Competencies of Graduates of Texas Nursing Programs. Austin: The Texas Board of Nursing.

The Texas Board of Nursing. (2015). Rules and Regulations Relating to Nurse Education, Licensure and Practice. Austin: The Texas Board of Nursing.
Table 1--Crosswalk of NPSF (2015) Recommendations to 217.11.
Standards of Nursing Practice and Differentiated Essential
Competencies of Graduates of Texas Nursing Programs (DECs)

NPSF Recommendation    Standard of Practice   Relationship

1. Ensure that         217.11.(1)(S):         Standards are
leaders                Make                   loosely
establish &            assignments            related. B
sustain a              that take into         speaks broadly
safety culture         consideration          to "safe
                       knowledge,             environment"
                       skill and              that is an
                       ability                element of
                                              safety culture.
                       Promote a safe

                       Clarify any order or
                       treatment as needed

                       Accept assignments
                       that take into
                       knowledge, skill
                       and ability

2. Create              217.11.(1)(P):         Loosely associated-
centralized &          Collaborate with the   speaks to
coordinated            client and members     collaboration
oversight of patient   of the healthcare
safety                 team

3. Create a common     217.11(2)(A)(v) &      Evaluating responses
set of safety          (3)(A)(v): Assist in   to nursing
metrics that reflect   the evaluation and/    interventions using
meaningful outcomes    or evaluate client's   a systematic
                       responses              approach

4. Increase funding    N/A                    N/A
for research in
patient safety &

5. Address safety      217.11(1)(B):          Promote safe
across the entire      Promote a safe         environment; clarify
care continuum         environment            orders; consult to
                                              achieve continuity
                       217.11.(1)(N):         of care
                       Clarify any order or
                       treatment as needed

                       217.11(1)(A): Follow
                       all laws, rules and

                       Accept assignments
                       that take into
                       knowledge, skill and

6. Support the         217.12(6)(F):          Disruptive
health care            Misconduct that is     behaviors; workplace
workforce              based upon an action   violence
                       that is threatening
                       or violent behavior
                       in the workplace

7. Partner with        217.11(1)(P):          Collaboration with
patients and           Collaborate with the   patients and others;
families for the       client and members     Education
safest care            of the healthcare

                       participate in
                       education to clients
                       and families

                       Promote a safe

8. Ensure technology   217.11(1)(H):Obtain    Orient & train on
is safe & optimized    orientation/           new equipment &
                       training for           technology
                       competency as needed

NPSF Recommendation    DECs                   Relationship

1. Ensure that         I A-D: II D;           > Scope of
leaders                III A-F:                 practice
establish &            Be a member of
sustain a              the profession         > Responsibility
safety culture         and a patient          & accountability
                       advocate,              > Safe
                       providing                compassionate,
                       patient                  comprehensive
                       centered care,           nursing care
                       adherence to
                       all laws, scope
                       of practice,
                       for quality,
                       promoting the
                       development of
                       practice, and
                       through life-
                       long learning.

2. Create              I A-D; II A-C : Be a   > Scope of practice
centralized &          member of the
coordinated            profession,            > Responsibility &
oversight of patient   providing patient      accountability
safety                 centered care in
                       collaboration with
                       the healthcare team
                       and through
                       adherence to scope
                       of practice,
                       responsibility and
                       accountability for
                       quality, promoting
                       the development of
                       nursing practice,
                       and ensuring
                       competence through
                       life-long learning

3. Create a common     II C: Report,          > Assessment data to
set of safety          analyze and            identify problems,
metrics that reflect   synthesize data for    formulate goals, &
meaningful outcomes    the development of     develop plans of
                       goals/outcomes in      care
                       collaboration with
                       the healthcare team.

4. Increase funding    NA                     N/A
for research in
patient safety &

5. Address safety      I A; II D; III A-F;    > Scope of practice
across the entire      IV A-G: Be a member
care continuum         of the profession by   > Provide safe,
                       functioning within     compassionate care
                       the scope of
                       practice in            > Knowledge of NPA &
                       accordance with all    Rules
                       laws and rules,
                       providing patient      > Collaboration,
                       centered care in the   communication
                       provision of safe,
                       nursing care,
                       advocating for
                       patient safety when
                       assignments and
                       seeking instruction
                       as needed, and
                       collaborating with
                       the healthcare team
                       in the promotion of
                       optimal health.

6. Support the         NA                     NA
health care

7. Partner with        II D-H; III A-F; IV    > Develop,
patients and           A-G: Provide patient   implement, &
families for the       centered care ,        evaluate care with
safest care            safe, compassionate,   patients & families
                       quality nursing
                       care, advocating for   > Communicate,
                       patient safety when    collaborate;
                       communicating          Referrals; Advocate
                       important patient
                       data and information
                       with the healthcare
                       team to collaborate
                       in the formulation
                       of goals that
                       promote optimal

8. Ensure technology   IV E: Be a member of   > Using technology
is safe & optimized    the healthcare team    to support decision-
                       by communicating       making
                       patient data using
                       technology to
                       support decision-
                       making and improve
                       patient care.
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Publication:Texas Board of Nursing Bulletin
Date:Jul 1, 2016
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