Errors in health care are one of the leading causes of death and injury in this country, requiring new methods for evaluating and promoting quality in health care services. Concern for patient safety, the foundation for quality services, has prompted national initiatives to examine the most basic premise for health care providers: Do no harm to the patient. Few of these initiatives have examined errors from the perspective of those who have been sanctioned for their errors. This descriptive, exploratory study utilized a survey methodology to examine the perceptions of 62 registered nurses (RNs) who had been sanctioned by a board of nursing to ascertain categories of practice errors and identify individual, health care team, patient, and system threats that contributed to an error and/or patient harm. The Threat and Error Management Model (TEMM) was utilized as a framework for examining the phenomena that promote or hinder patient safety. Using a modified version of the Taxonomy of Error Root Cause Analysis of Practice-Responsibilities (TERCAP) instrument, sanctioned RNs selected types of errors associated with a breakdown in their nursing practice. In addition, they identified factors that contributed to their errors, including individual, health care team, patient, and system threats. Associations between the levels of patient harm and types of error were examined. Two open-ended questions provided an opportunity for the participants to describe changes in their practice since the error event. System and health care team factors were the most common items selected as contributing to the error events, while individual factors were the least often selected items. Two types of errors, clinical evaluation and attentiveness/surveillance, were significantly related to the level of harm to patients. Given the opportunity to discuss individual factors through open-ended questions, responses were comprehensive and many were related to issues with trust. Recommendations for nursing theory, policy, practice, education, and research are reviewed.

Submitted in Fulfillment of the Requirements of the Degree of Doctor of Technology: Nursing Sciences, Durban University of Technology, Durban, South Africa, 2012. / Introduction While investigating alleged unprofessional conduct involving nurses, SANC collects a wealth of information which is used as the basis upon which to determine the nurses’ guilt or innocence in respect of unprofessional conduct. No evidence exists that such information is ever used to determine how similar acts of unprofessional conduct could be prevented and/or be used in mitigating the impact of such acts on patient safety. Given that nurses have most interaction with patients, there is much to learn from practice breakdown involving nurses. Methods A four phase cross sectional sequential exploratory mixed method approach using a modified soft system methodology (SSM) methodology was utilised to develop a framework for the integrated management of practice breakdown. Purposive sampling was followed to select five districts in KwaZulu-Natal for inclusion in the study. In addition Operational Nursing Managers, members of the Professional Conduct Committee of the South African Nursing Council, and representatives of organised labour were purposively sampled. Qualitative data regarding causes and current practices in the management of practice breakdown in the nursing profession was gathered from key groups via focus groups, and individual phone calls. Then a survey instrument used to test the elements of the emerging theory was developed. Finally, a framework for integrated management of practice errors is suggested. Results The study found that practice breakdown was a product of both environmental factors such as fallible managerial decisions, and unintended acts committed by nurses. In addition, the types of errors and consequences of error management were identified. Finally, conditions requisite for the integrated approach in the management of practice breakdown were identified and used to develop a framework for an integrated approach in the management of practice breakdown in nursing. Conclusion Creation of a positive practice environment for nurses is requisite for an integrated approach in the management of practice breakdown. / Appendices only available in the Hard copy of the Thesis / D