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Learning Objective 1: Describe the key practice variances identified in the study.
Learning Objective 2: Discuss actions plans that can transform the nurses’ work environment
Methods: A systematic retrospective record review of the NPR investigations was conducted to quantify nursing practice variances. Data was collected based on the taxonomy of error incorporating environmental factors contributing to practice variances developed by National Council of State Boards of Nursing (NCSBN) and the unprofessional conduct developed by the TBON.
Results: Seventy eight records were reviewed from 2005 to 2009 using the eight components of patient safety that are central to the nursing role. The components include safe medication administration, documentation, attentiveness/surveillance, clinical reasoning, prevention, intervention, interpretation of authorized provider orders, and professional responsibility/patient advocacy. Analysis of the records showed the most frequent variance was in professional responsibility.
System barriers and external factors were not found not to be a factor in 41% of the records reviewed. In the remaining records, organizational and work environment were identified as the leading systems barriers.
Conclusion: One limitation is that there was only one study site. Consistency of documentation may also limit study findings.
This presentation will detail the findings of the research study and its implications to transforming the work environment of nurses.
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