These case studies are submitted by the North Carolina State board of Nursing, written by Julie George, PREP Program Coordinator. If you'd like to submit your cases to us, please use our contact page, or simply e-mail us!

Case #1--a 50 y/o female RN, with 30 years of nursing experience and 21 years experience at the employing hospital --described by hospital as having excellent clinical skills and unblemished performance record.

Nurse 'A' performed needle insertion for induction of spinal anesthesia on a patient who was scheduled for surgery. She said she had always wanted to know what the "pop" felt like when you entered the spinal space. Nurse 'A' was not a CRNA and was not authorized by law to implement anesthesia activities.

Case #2--a 31 y/o male RN with seven (7) years of experience and five (5) years experience with the employing hospital--described by hospital as having excellent clinical skills and no prior performance concerns.

Nurse 'B' felt sick at work and said he suffered from severe allergies. He obtained injectable Benadryl from the hospital pharmacy and administered the drug to himself, in an attempt to feel well enough to remain on duty. Nurse 'B' was not authorized by law to prescribe or dispense legend drugs.

In both of the above cases, the individuals realized they did something wrong and both felt their actions resulted from a lack of knowledge of the legal scope of practice. Neither nurse had ever been the subject of disciplinary action by the Board. Incidents similar to these have historically resulted in formal letters of Reprimand (formal discipline, reportable to national data bank) from the Board for Exceeding Legal Scope of Practice. As employees of a PREP pilot hospital, both licensees were eligible for consideration for the NC PREP program. Prior to acceptance into the PREP program, both licensees were interviewed by the PREP Coordinator. Additionally, background information was obtained from the employers and disciplinary information was checked in NURSYS. There was no patient harm involved in either incident. After discussion with the nurse managers involved, it was mutually recommended that remediation include formal education related to Legal Scope of Practice. After the recommended educational intervention, the licensees will be asked to write a paper demonstrating understanding of their errors and articulating integration of new knowledge into future practice. Since both cases involved isolated incidents not felt to be representative of either licensee's usual practice, no formal workplace monitoring was recommended.

Case #4 involved competency deficit in older nurse who is now working in a hospital on the Mother/Baby unit. This nurse had already been reassigned by the hospital (off of Labor & Delivery) because of lack of skill. Hospital had made efforts to re-train, etc. and weren't being successful. They referred her to PREP. She was assessed by the Nurse Educator for Womens/Childrens division of hospital. The nurse educator then recommended specific educational interventions available through the hospital.

Case #5 involved another case of a minor violation of our NPA, exceeding legal scope of practice, administering medication without a legitimate physician order. In instances where remediation is "complete", they (our first 3 cases) have been isolated incidents/errors and remediation consisted of only an educational intervention, no on-going monitoring. Following completion of the educational intervention, the licensees have provided a written response to demonstrate that they understand the nature of their actions and have gained knowledge needed.

Case #6 involved an experienced RN, licensed since 1984. This licensee returned to the acute care setting (hemodialysis) after several years away from acute care and having no prior experience in dialysis. Although successful in general orientation, the licensee was involved in two serious events with potential for patient harm. In the first event, the licensee incorrectly connected dialysis equipment. In the second event, she erroneously administered Epinephrine to a patient with tachycardia, rather than Digoxin, as ordered by the physician. After assessment and reflection by both the nurse and the hospital, it was determined that a transfer to PACU, where she had prior experience, would be in the best interests of both. Additionally, the licensee agreed to complete comprehensive remedial education and work under supervision and monitoring for a period of one year.

Case #7 involved a relatively inexperienced RN, initially licenced in 1999. This licensee committed a serious medication error, where she miscalculated a medication dose. After assessment, the licensee agreed to remedial education related to NICU medications, calculations and errors. All calculations will be monitored by another nurse for a period of 3 months, and the licensee's practice will be monitored for a period of one year. As part of her agreement, the licensee will review current literature and national benchmarks related to medication administration for neonates. That information will then be used for review and revision of hospital procedures.

In both cases, the hospital was very open in examining some possible systems issues related to the incidents and discussing the corrective measures they have taken. This truly seemed to be PREP working as it was envisioned--a trusting relationship between hospital and board, where both individual and system have opportunity for improvement!

We congratulate the North Carolina Board of Nursing for moving forward with appropriate educational/remedial interventions in these, their first two cases. PREP was conceived in the first instance to identify and remediate knowledge and skill deficiencies that expose patients to potential harm as a result of sub-competent practice. The first five first cases put a particular twist on the matter, since the identified deficiency is a lack of knowledge about scope of practice. If this lack of knowledge is not corrected, practitioners may expose patients to harm by attempting to deliver services or perform tasks for which they have not been adequately trained. We especially like that part of the intervention that asks the involved nurse to write a paper demonstrating that the educational intervention has worked!