TBON Peer Review

The Texas Board of Nursing Rules and Regulations (TBON), the Texas Nurse Practice Act (NPA) and the Texas Occupations Code (TOC) guide nursing practice by defining nursing actions and mandating that nurses perform their jobs appropriately. The TBON utilizes the NPA and TOC to review cases with which there are questions regarding the scope of practice and delegation of duties. Of the two cases to be reviewed the first involves a nursing task, administration of blood products and Foley catheter insertion that was delegated incorrectly. The improper delegation of duties by a MD to a paramedic and the RN’s responsibility will be evaluated according to the Texas Nurse Practice Act, the Texas Board of Nursing Rules and Regulations and standards for blood transfusion. The second case will explore the peer review process by evaluating a case involving a RN working in a clinic.

Jane is a RN who has been sent to peer review for unprofessional behavior and practicing outside her scope of practice. She was reported to be completing full medical exams including pap smears and bilateral breast exams. Jane and a physician had an agreement for at least the past 18 months where the MD was signing off on the charts as if he had seen the patients.
According TOC § 303.001 (5)(A-D) Peer review is as “the evaluation of nursing services, qualifications, quality of patient care, and the merits of a complaint concerning a nurse.” The process is one of fact finding, analysis and studying events by nurses focused on obtaining relevant information about an event. As defined by TBON § 217 unprofessional conduct and unsafe practice also applies to the management of client records; failure to practice within a modified scope of practice or with the required accommodations, as specified by the board in granting a coded license or any stipulated agreement with the board. A Nursing Peer Review Committee (PRC) is defined in § 303.001 of the TOC as a committee that is established in order to conduct peer review. The committee is given authority by the governing body or organization that formed it. Nursing peer review committee (PRC) is established under the authority of the governing body of a healthcare organization for the purpose of conducting peer review. The committee includes an employee, an assistant, an investigator, an intervener, an attorney, and any other person who serves the committee in any capacity and is established to conduct nursing peer review under Section 303.0015. TOC § 303.003(a-d) discusses the composition of the PRC. A Nursing Peer Review Committee for RNs must have the following: three-fourths of its members must be nurses, two-thirds must be registered nurses, there should be at least one nurse who is familiar with the nursing practice that is being reviewed if possible, and all voting members must be registered nurses.
The Texas Board of Nursing Rules and Regulations mandates that the nurse undergoing an Incidence Based Peer Review (IBPR) is guaranteed certain rights, or minimum due process. According to TBON § 217.19 (d)(1-6) what is required to meet minimum due process. The facility must have written policies that will dictate the who, what, where, when and how regarding an IBPR. The employee should be notified in writing of all details regarding the incident to be reviewed and when and where the review process will take place well in advance. The nurse has the right to defend her actions by actively participating in the proceedings, including obtaining legal counsel or can choose not to participate, thereby waiving her right to due process. The committee is required to perform the review in a timely manner then notify the nurse in writing of their findings. The nurse has the right to submit a written rebuttal, should she feel the committee’s ruling is unjust. The committee must keep an official record of the peer review proceeding on file and must comply with all voting and membership requirements. The issues the PRC have to consider in this situation include actual clinical evidence such as copies medical records, copies of the prescriptions’ written and any corrective actions taken against the employee (Jane). Information should be included about the physician who was signing off and documenting that he had seen the patient, since this had been the practice between Jane and the physician for at least the last18 months. The NPA § 301.002 states that professional nursing does not include "medical diagnosis or prescription of therapeutic or corrective measures." Which means a RN may not use of independent medical judgment to examine, treat or diagnose a patient’s medical condition According to TBON §217.19(a)(7) the role of the IBPR is to determine if the nurse’s actions should be reported to the board of nursing. The IBPR makes recommendations that the employee, employer, and TBON can take into consideration, it is not responsible for making employment or discipline decisions. The IBPR must consider if the RN’s actions placed the patient at risk and if the RN was conducting herself professionally. The PRC also had to consider whether the RN’s actions were due to factors beyond her control or if she exhibited a deficiency in judgment, knowledge, training or skill as mandated by TOC § 303.011(a). The actions of the nurse went beyond the scope of nursing practice thereby placing the patient at risk according to TBON §217.11(1)(K)(iv). Jane’s actions were not with-in the scope of professional nursing as defined in NPA § 301.002(2).
Since Jane was suspended for 14 days this incident had to be reported and could not fall under a minor incident. The NPA § 301.405 (b) mandates that if an RN is suspended for 7 or more days the employer is required to report her to the Board of Nurse Examiners. The employer may take disciplinary action prior to conducting Incident-Based Peer Review according to the NPA § 301.405(e). Employment and licensure are two separate issues. According to TBON § 217.16 (3)(A-B) the PRC may consider the RN’s actions in the particular setting, such as her experience, as well as any system problems or factors beyond the RN’s control, for example organizational policy or the lack thereof.
A minor incident is defined by NPA § 301.401 (2) and means that a RN does not need to be reported to TBON if her continued practice would not put her patient’s in harm’s way. In this event scenario there was no harm caused to the patients but even so I do believe that this event could not be considered a minor event and had her employer should have suspended the RN, and it does require reporting to the TBON. The administration was bound by duty to refer Jane’s case to PRC according to NPA § 301.405. This section explains a person that is suspends for more than seven days, or takes other substantive disciplinary action defined by the Board against a nurse’s conduct is subject to reporting to the board. The report must include the following; the identity of the nurse; the conduct subject to reporting that resulted disciplinary action; and any additional information requested.
Nurses are required to make decisions regarding patient care every day. The Texas Board of Nurses has provided guidelines on how to make those decisions and what will happen if the wrong decision is made. The rules and regulations were put in place to protect the nurse and the public that is served. Complying with the Nurse Practice Act along with other rules insures a long and fulfilling career for nurses and appropriate care for their clients.
Reference Page
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Medical-Surgical Nursing (11th ed.) (Vols. 1-2). Philadelphia, PA: Lippincott Williams & Wilkins.
Board of Nurse Examiners for the State of Texas (2009). Nursing practice act, Nursing peer review act. Retrieved April 9, 2010, from http://www.bon.state.tx.us/about/pdfs/npa2009.pdf Board of Nurse Examiners for the State of Texas. (2009, September). Nursing Peer Review Frequently
Asked Questions. Retrieved April 9, 2010, from http://www.bon.state.tx.us/practice/pdfs/FAQ-PR.pdf Board of Nurse Examiners for the State of Texas. (2009, July). Rules and regulations relating to nurse education, licensure and practice. Retrieved April 9, 2010, from http://www.bon.state.tx.us/nursinglaw/pdfs/bon-rr-0709.pdf Davidson, M. R., Ladewig, P. A., & London, M. L. (2008). Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan (8th ed.). Upper Saddle River, New Jersey: Pearson Prentice Hall.