Taxonomy of Error, Root Cause Analysis Practice-Responsibility

The Arizona State Board of Nursing is a participating Member Board of the National Council of State Boards of Nursing (NCSBN) TERCAP project. The TERCAP project was implemented in 1999 by NCSBN’s Board of Directors who appointed a task force to develop new knowledge about the causes of nursing practice breakdown.

In 2004, the following recommendation was made in the Third Institute of Medicine (IOM) Report on patient safety entitled, Keeping Patients Safe, Transforming the Work Environments of Nurses (2004):

Recommendation 7.2: The National Council of State Boards of Nursing [NCSBN], 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 applicability by state boards of nursing and other state regulatory bodies (IOM, 2004, p. 15).

TERCAP was designed as an intake instrument for capturing data from nursing boards' discipline cases. It creates an opportunity for consistent data collection and future analysis of compiled data by NCSBN and Member Boards.

The Arizona State Board of Nursing may request additional information for the purpose of TERCAP.

What is the purpose of TERCAP?

The purpose of TERCAP is to provide an instrument used by boards of nursing as an intake instrument for capturing data from discipline case files to feed into a national data set.

  • Root cause of practice breakdown
  • Nurse characteristics
  • Patient characteristics
  • Types of nursing practice breakdown
  • System characteristics associated with the error


  • Consistent and comprehensive data collection
  • Track case elements and recurring themes
  • Learn from the experience of nurses who have had episodes of practice breakdown
  • Discover characteristics of nurses at risk

What might we learn?

  • How are errors identified?
  • When and where do errors occur?
  • Can errors be "recovered from" by counteractions?
  • What are ways to trigger those counteractions?
  • Will changes in systems effect error tolerance?
  • Could unintended side effects create new paths to failure?
  • Can we find deeper, more generic patterns in failures?
  • How to develop, prototype and evaluate new approaches to patient safety?
  • Can we begin to anticipate new areas of concern?

TERCAP Classifies Breakdown Into 10 Categories

  • Patient Profile
  • Patient Outcome
  • Setting Where Practice Breakdown Occurred
  • System Issues
  • Health Care Team
  • Nurse Profile
  • Intentional Misconduct or Criminal Behavior
  • Practice Breakdown Category: Safe Administration of Medication
  • Practice Breakdown Category: Documentation
  • Other Practice Breakdown Categories:
    • Attentiveness / Surveillance
    • Clinical Reasoning
    • Prevention
    • Intervention
    • Interpreting Authorized Providers' Orders
    • Professional Responsibility and Patient Advocacy

TERCAP Instrument

The TERCAP Electronic Form (PDF) can be downloaded for use by any facility. This instrument can also supplement the complaint form submitted to the Arizona State Board of Nursing office.

TERCAP Data Collection Instrument Including Guidelines From Protocol For Instrument Use (PDF)


The following questions are frequently asked about TERCAP:

Q:  What is “practice breakdown”?
A:  Practice breakdown involves healthcare situations when some aspects of essential nursing practice expectations are not met.

Q:  On what kinds of cases should TERCAP be used?
  Cases that involve some aspect of practice breakdown.

Q:  How can I get the TERCAP instrument?
  TERCAP Electronic Form (PDF)

Q:  When did the Arizona State Board of Nursing start utilizing the TERCAP instrument?
  December 15, 2007

Q:  Will you disclose my name and license number?
  No, the identity of the nurse is not revealed.

Relevant Articles

  • TERCAP: Creating A National Database On Nursing Errors
  • Nursing And Patient Outcomes: How Can Employers Provide The Right Environment For Nurses To Deliver High Quality Care?
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