• Engaging in ongoing employee training in error detection, analysis, and reduction.

  • Implementing procedures for analyzing errors and providing feedback to direct-care workers.

  • Instituting rewards and incentives for error reduction.

Recommendation 7-2. The National Council of State Boards of Nursing, in consultation with patient safety experts and health care leaders, should undertake an initiative to design uniform processes across states for better distinguishing human errors from willful negligence and intentional misconduct, along with guidelines for their application by state boards of nursing and other state regulatory bodies having authority over nursing.

Recommendation 7-3. Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by HCOs for internal use or shared with others solely for purposes of improving safety and quality.

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