NCSBN's new book examines instances of nursing practice breakdown

The National Council of State Boards of Nursing (NCSBN®) announces the release of "Nursing Pathways for Patient Safety," a new book which advocates an innovative approach to examining instances of nursing practice breakdown.

Published by Elsevier Mosby, "Nursing Pathways for Patient Safety" is written by a distinguished panel of NCSBN experts seeking to create a change in the current state of health care safety management. This book examines the issues surrounding practice breakdown in a way that looks beyond individual errors and instead, examines practice breakdown from a systems perspective.

One of the book's editors, Patricia Benner, PhD, RN, FAAN, Visiting Professor, University of Pennsylvania, and Senior Scholar for the Carnegie Foundation for the Advancement of Teaching, comments, "This book is a 'must read' for all undergraduate and graduate nursing students, as well as all practicing nurses, and nurse educators and administrators. It clarifies and exemplifies the nurse's central role in patient safety. Nurses are the patient's first and last defense in today's complex health care system. Central to their work is the prevention of safety hazards to patients as a result of hospitalization or encounters with all health care institutions."

A culmination of NCSBN's Practice Breakdown Initiative, the book describes the TERCAP® (Taxonomy of Error Root Cause Analysis and Practice-responsibility) data collection instrument and provides a systematic review of eight types of practice breakdowns. Factors that may contribute to practice breakdown have been identified, including:

-- Patient Profile; -- Patient Outcome; -- Setting; -- System Issues; -- Health Care Team; -- Nurse Profile; and -- Intentional Misconduct or Criminal Behavior.

Coverage of each type of practice breakdown, such as clinical reasoning or judgment, prevention and intervention, is systematically explored.

The book provides compelling case studies in each chapter based on actual instances of practice breakdown. Chapters on mandatory reporting and implementation of a whole systems approach offer practical information on understanding TERCAP® and provide a helpful framework for grasping the scope of problems, along with NCSBN's approach to addressing them.