JPisculli_TERCAP_120320.docx - 1 TERCAP Proposal John...

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1 TERCAP Proposal John Pisculli Rasmussen University NUR4327CBE David Campbell-ODell December 3, 2020
2 TERCAP Proposal A TERCAP Proposal is a report done after an incident that takes many factors into consideration such as the patient profile, patient outcome, setting in which the event occurred, system issues, healthcare team, nurse profile, intentional misconduct, medication administration, documentation, attentiveness, clinical reasoning, prevention, intervention, provider orders and professional responsibility. This program is intended to help understand all of the potential factors that lead to the event and what could have been done to prevent it from happening. It also can help lead education and policy changes for the facility to help reduce risk for future events. ( Arizona State Board of Nursing ) In the case given, there were many factors that contributed to the event that occurred. Risk factors can be broken up into four categories: situational, nursing, human and organization. The biggest situational factor in this case were the fact that the patient was first day post- operative. This means that the patient had just returned from surgery before the oncoming nurses shift. The patient needed help with ambulation for at least the next 24 hours due to the pain medication and post-anesthesia response. This an important factor to consider due to it being the underlying cause for the fall. In order to reduce the risk for future falls in the facility’s post-op patients, the nurses should prioritize assessment of the effects of the patient’s medications, assistance in walking with patient and evaluate blood sugars due to the extended period of fasting before and after the procedure. Some examples of the nursing factors would be the fact that this was a more recent graduate nurse on her 3 rd night shift in a row with a patient load of 14. With that many patients per nurse with only one assistive personnel, the amount of time this nurse would have been able to spend with each patient would be extremely limited and her workload would have been a lot for her. This may have hindered her ability to round as she
3 normally would. Also, with having 14 patients, she would not have been able to know as much

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