hospital’s Peer Review Committee (PRC). You are reviewing Nurse A’s practice. She works on the pediatric unit. In the past, Nurse A has practiced safely without incidents. However, four months ago, Nurse A gave immunizations to five pediatric patients (3 months, 9 months, 2 years, 4 years, and 5 years of age). She used a vial of Hepatitis B vaccine that had been expired for 30 days but still was being stored in the unit refrigerator. She gave the five immunizations within a few minutes of each other, and she got the vial from the refrigerator only once (i.e., She did not take it out and replace it five times). She took responsibility for the errors when she was informed by her unit manager.
Should Nurse A be reported to the BON?
Let’s review what deems a minor vs. a reportable (NOT minor) incident-
A minor incident is- 217.16(a)- as defined under the Texas Nursing Practice Act, Texas Occupations Code §301.401(2), means conduct by a nurse that may be a violation of the Texas Nursing Practice Act or a Board rule but does not indicate the nurse’s continued practice poses a risk of harm to a patient or another person.
A reportable incident is- 217.16(h)- conduct that falls outside of the definition of a minor incident and must be reported to a PRC or BON.
Apply the Minor Incident Rule to reach and support your decision. This Rule 217.16 can be found at http://www.bon.texas.gov/rr_current/217-16.asp
Use this specific link only- it is the official updated Texas Board of Nursing information. Click on the link and scroll down to the bottom to find the letter (h), where criteria are listed that describes actions that must be reported to the Peer Review Committee or BON.
Criteria. In the first column of the table, list the 5 criteria as it appears in the rule that are essential in determining if an incident is a reportable action. All 5 must be listed for full credit. Then, in the second column, record your explanation as to why or why not the nurse’s actions deem it reportable and therefore harmful to a patient.
Criteria that determine an incident is reportable
Explanation of whether or not Nurse A’s actions are minor vs. reportable