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Frequently Asked Questions - Nursing Peer Review

General Peer Review Information

What is Peer Review? [Nursing Peer Review (NPR) §303.001(5)]

Peer review is the evaluation of nursing services, the qualifications of a nurse, the quality of patient care rendered by nurses, the merits of a complaint concerning a nurse or nursing care, and a determination or recommendation regarding a complaint including:...Toggle Expand/Collapse Text

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What is a nursing peer review committee? [NPR §303.001(4); 22TAC 217.19(a)(14), 217.20(a)(14)]

It is a committee established under the authority of the governing body of a national, state, or local nursing association; a school of nursing; the nursing staff of a hospital, health science...Toggle Expand/Collapse Text

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Who must have a peer review plan? [NPR §303.0015 ]

Any person or entity that employs, hires, or contracts for the services of 10 or more nurses (RNs, LVNs or any combination thereof) must have a Peer Review Plan; however, peer review of RNs is not mandatory if the facility employs less than 5 RNs. A person or entity required to have nursing peer review may contract with another entity to conduct nursing peer review.

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What is the Peer Review committee’s composition? (NPR §303.003)

NPR law, Section 303.003 (a) requires that a Nursing Peer Review Committee that conducts a review that involves the practice of registered nurses and licensed vocational nurses must have registered nurses and licensed vocational nurses as 3/4 of its members;...Toggle Expand/Collapse Text

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What part of the Peer Review process is confidential? [NPA §303.006-.007; §303.0075, Rule 217.19(h), §217.20(j)]

All proceedings of the nursing Peer Review committee are confidential and all communications made to the committee are privileged. All information made confidential is not subject to subpoena...Toggle Expand/Collapse Text

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To whom may the Safe Harbor Peer Review (SHPR) Committee disclose privileged information (NPR §303.007)?

Upon written request, the committee shall disclose written or oral communications and the records and proceedings of the committee to:...Toggle Expand/Collapse Text

Is it acceptable to use an informal work group of the peer review committee for either incident-based or safe harbor peer review? Do the same time lines apply for conducting the review when using an informal work group of the peer review committee? [Rule 217.19(e) or 217.20(k)]

Yes, any entity conducting peer review may choose to use a smaller work group of the peer review committee for either incident-based or safe-harbor peer review. A nurse involved as...Toggle Expand/Collapse Text

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Can we just use the BON Nursing Peer Review statutes and rules as our facility/agency policies and procedures on Nursing Peer Review?

No, many other details must be included in peer review policies and procedures in order to have an operational peer review committee structure. As the BON does not regulate practice settings of any kind, the Board does not have authority to prescribe every aspect of peer review at the facility or employer level....Toggle Expand/Collapse Text

Examples of issues that must be addressed in facility policies include (but are not limited to):

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What records should a peer review committee chairperson maintain, and for how long? What records should the PRC chairperson send to the board when subpoenaed by the BON to send “all nursing peer review records related to “Jane Doe RN?”

The NPR statute does not specify requirements related to records retention of peer review proceedings, nor has the board established any time frame by rule. With the ability to scan and save documents in a digital format, the BON would encourage facilities and employers to consider this...Toggle Expand/Collapse Text

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What whistleblower protections does a nurse have if he/she reports a facility, agency, school or other entity that provides healthcare services, or a physician or other licensed practitioner for endangering patients/clients or engaging in unethical or illegal conduct? [NPA§ 301.4025, §301.413]

The above listed sections of the NPA Chapter 301, and Rules 217.19(m) and 217.20(l) address protections a nurse has when reporting unsafe practices of practitioners other than nurses (such as physicians, dentists, etc) or entities (such as hospitals, nursing homes, home health...Toggle Expand/Collapse Text

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Incident-Based Nursing Peer Review

What “due process” rights must the peer review committee provide to the nurse undergoing Incident-Based Peer Review (IBPR)? [ Rules 217.19(d)]

Review of NPR Chapter 303 in its entirety is recommended, as compliance with various sections of this chapter is necessary to assure compliance with “due process” and “good faith” peer review requirements. Rule 217.19(d) delineates specific requirements for minimum due process...Toggle Expand/Collapse Text

May the employer take disciplinary action prior to conducting Incident-Based Peer Review? [ NPA 301.405(e)]

Employment and licensure issues are separate. An employer may take disciplinary action before review by the peer review committee is conducted, as peer review cannot determine issues related to employment. The role of peer review is to determine if licensure violations have occurred and,...Toggle Expand/Collapse Text

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Does an employer have to report to the Board if they terminate a nurse, or make an agency nurse a “do-not-return,” for practice-related errors? [Section 301.405 (b)]

If an employer terminates a nurse for non-practice-related reasons (such as too many absences, or non-patient-related misconduct) this is an employment, not licensure, issue and is not board-reportable....Toggle Expand/Collapse Text

Does the Incident-based Peer Review (IBPR) Committee have to meet if the nurse voluntarily resigns or is involuntarily terminated for practice related reasons? Does the nurse have due process rights under peer review if a report to the BON is already mandatory under NPA §301.405(b) or §301.402(b)? [NPA §301.405(c) and Rule 217.19(f)(1)]

SB993 (80th Legis. Session, 2007) amended NPA ( TOC) §301.405(c) requiring that even if a mandatory report by the employer has been, or will be, made to the BON under §301.405(b), the...Toggle Expand/Collapse Text

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Must the recommendations made by the Incident-based Peer Review (IBPR) Committee be followed by the employer?

The nursing peer review committee does not have authority to make employment or disciplinary decisions. The employer must make their own decision about appropriate disciplinary...Toggle Expand/Collapse Text

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What is a Minor Incident? [NPA301.419(a), Rule §217.16(b)]

A "minor incident" is defined by Texas Occupations Code (Nursing Practice Act) §301.419(a) as "conduct that does not indicate that the continuing practice of nursing by an affected nurse poses a risk of harm to the client or other person."

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Are there Exclusions to What Can Be Considered a Minor Incident? [Rule 217.16]

Yes. Rule 217.16(c) defines 3 types of circumstances in which the conduct cannot be considered a minor incident:

  1. Any error that contributed to a patient’s death;
  2. Criminal conduct defined in NPA 301.4535; or
  3. A serious violation of the board’s Unprofessional Conduct Rule 217.12 involving intentional or unethical conduct such as fraud, theft, patient abuse or patient exploitation.

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What are the criteria for determining if Minor Incidents are Board reportable?

Rule 217.16(d) establishes when a minor incident is or is not board-reportable:...Toggle Expand/Collapse Text

What is the Peer Review committee required to report? [NPA §301.401, 301.403, & Rule 217.11, Rule 217.12, Rule 217.16]

A peer review committee is required to make a report to the Board if they believe in good faith that a nurse has engaged in conduct subject to reporting as defined under the Nursing Practice Act (NPA), §301.401(1). This nearly always involves one or more suspected violations of...Toggle Expand/Collapse Text

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If a nurse’s practice is suspected of being impaired secondary to chemical dependency, drug or alcohol abuse, substance abuse/misuse, “intemperate use,”mental illness, or diminished mental capacity, must Peer Review be conducted and a report filed with the Board? [NPA §301.410 & Rule 217.19(g)]

It depends. If there is no evidence of nursing practice violations, a nurse may be reported to either the BON or to a peer assistance program [Rule 217.19(g)(1)]....Toggle Expand/Collapse Text

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Who conducts Peer Review for a temporary or contract employee? (NPR §303.004)

The nurse who works through a temporary agency or contractor may be subject to Peer Review by either the facility where services are provided, the compensating agency, or both. For purposes...Toggle Expand/Collapse Text

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Safe Harbor Peer Review

What is Safe Harbor? [NPR §303.005(b) and (e); Rule 217.19(a)(15), Rule 217.20(a)(15)]

Safe Harbor is a nursing peer review process that a nurse may initiate when asked to engage in an assignment or conduct that the nurse believes in good faith would potentially result in a violation of Board Statutes or Rules. When properly invoked, safe harbor protects a nurse from...Toggle Expand/Collapse Text

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What protections of a nurse's license are applicable under Safe Harbor? [NPA §301.352, §301.413; NPR §303.005(c), (d), and (h),]

A nurse who in good faith requests Safe Harbor peer review:

  1. may not be disciplined or discriminated against for making the request;
  2. may engage in the requested conduct pending the peer review;
  3. is not subject to the reporting requirement under Subchapter I, Chapter 301; and
  4. may not be disciplined by the board for engaging in that conduct while the peer review is pending.

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Where do I send my Safe Harbor request? Do I Fax it to the Board of Nursing?

Please DO NOT mail or fax your request for Safe Harbor Nursing Peer Review to the Board of Nursing. The BON cannot conduct Peer Review-this must be done through the facility or agency where the assignment was made to you. Please review the following questions, as well as the instructions on the Comprehensive Request for Safe Harbor form.

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How does a nurse invoke these protections? [Rule 217.20(d)]

To activate Safe Harbor protections, the nurse must:...Toggle Expand/Collapse Text

If a nurse invokes Safe Harbor, and the Supervisor subsequently is able to remedy the situation that caused the nurse to invoke Safe Harbor (such as obtaining more staff), is the nurse’s request for Safe Harbor invalid? Does the nurse have to withdraw his/her request for a nursing peer review committee to evaluate the nurse's request?

The nurse's request for Safe Harbor Peer Review does not become invalid and the nurse does not have to withdraw his/her request for Safe Harbor just because a supervisor is able to respond...Toggle Expand/Collapse Text

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When Can a Nurse Invoke Safe Harbor and Refuse the Assignment? [NPA (TOC) §301.352, Rule 217.20(g)]

The NPA, section 301.352 permits a nurse to refuse an assignment when the nurse believes in good faith that the requested conduct or assignment could constitute grounds for reporting the nurse to the board under NPA 301.401(1), could constitute a minor incident, or could...Toggle Expand/Collapse Text

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Does Safe Harbor Protect a Nurse from Civil or Criminal Liability? [NPR §303.005(h), 217.20(e)(2) & (3)]

No. Safe Harbor has no effect on a nurse’s civil or criminal liability for his/her nursing practice. The BON does not have any authority over civil or criminal liability issues. Safe Harbor does protect the nurse from retaliation by an employer or contracted entity for whom the nurse performs nursing services. There is no expiration of the protection against retaliatory actions such as demotion, forced change of shifts, pay cut, or other retaliatory action against the nurse.

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When Can a Smaller Workgroup of the Nursing Peer Review Committee be utilized?

A smaller workgroup of the nursing peer review committee may be used in either Safe Harbor or Incident-Based nursing peer review. The nurse involved in either type of peer review must agree to the use of the smaller workgroup. The nurse does not give up his/her right to review by the...Toggle Expand/Collapse Text

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Must the recommendations made by the Safe Harbor Peer Review (SHPR) Committee be followed by the CNO/Nurse Administrator?[NPR §303.005(d); Rule 217.20(j)(4)(A)]

NPR law §303.005(d) requires the employer/nurse manager to consider the decision of the SHPR Committee “in any decision to discipline the nurse.” The “non-binding” provision in this statute means that if the CNO/Nurse Administrator believes the SHPR was conducted in “bad faith,”...Toggle Expand/Collapse Text

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If you have additional questions regarding Peer Review, see Nursing Peer Review (TOC) Chapter 303 and BON Rules 217.19 and 217.20. Or see the following resource Safe Harbor Statutes and Rule References.Adobe Acrobat PDF pdf

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For more information on these and other topics, use the search field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.