1:00 p.m. Call to Order Board Meeting Nurses disciplinary hearing is scheduled but delayed due to the pandemic. U.S. The system provides licensure and publicly available discipline data directly to you as the information is entered into the Nursys database by participating boards of nursing. Board members, with few exceptions, are appointed by the Governor. For example, the Board considered neuromuscular blocking agent warnings on the ADC screen and shrink wrap sleeves over the vials to be red flags overlooked by RaDonda, when both had been added to improve the warning system after the event occurred. To be clear, nurses cannot be held accountable for achieving the five rights; they can only be held accountable for following the processes that their organizations have designed and held out as the best way to verify the five rights. Nurses criminal trial is scheduled but delayed due to the pandemic. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Undisputed failure. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. 4 0 obj The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. While the vast majority of nurses are competent and caring individuals who provide care according to the standard, violations of the nurse practice act do happen. endobj This timeline will help, Medication Safety Officers Society (MSOS). The Board relied on an incomplete investigation of the event, particularly related to the question, What normally happens in similar circumstances? For example, the investigation had failed to examine prior patients who were anxious about radiology scans due to claustrophobia to see what normally happensdid these patients receive oral anxiolytics or IV sedatives? 214 2nd Avenue N., See what boards of nursing are currently participating. The Administrative Procedures Division is the administrative court for the State. DISCIPLINARY ACTION REPORT . 1406 0 obj <> endobj These laws are defined in the Nursing Practice Act (NPA). Plymouth Meeting, PA 19462. The boards are also responsible for the investigation of alleged violations of the Practice Act and rules and are responsible for the discipline of licensees who are found guilty of such violations. If allegations against a nurse are proven, or he or she admits to the allegations, a board of nursing has the authority to discipline the nurse. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Time: 1:00 p.m. C.T. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . Inability to differentiate between human error, at-risk behavior, and reckless behavior. The location of the licensee's primary practice setting; A description of any criminal convictions for felonies and, as determined by the board, serious misdemeanors, within the most recent ten (10) years. Undisputed failure but most likely at-risk, not reckless, behavior. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. ); Names of medical schools or professional and training schools and dates of graduation; Graduate medical education or other graduate-level training; Specialty board certification as determined by the relevant board; Names of the hospitals where the licensee has privileges; The identification of any translating services that may be available at the licensee's primary practice location; An indication of which managed care plans in which the licensee participates; An indication of TennCare plans in which the licensee participates; Appointments to medical school faculties and indication as to whether a licensee has a responsibility for graduate medical education within the most recent ten (10) years; (optional), Information regarding publications in peer-reviewed medical literature; (optional) and, Information regarding professional or community service associations, activities and awards; (optional). Nursys is the only national nurse licensure and disciplinary database. Table 2. . Nurse did not verify that the proper medication was removed from the ADC. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . For the purposes of this subsection (a), a person shall be deemed to be convicted of a crime if such person was found or adjudged guilty by a court of competent jurisdiction. "9$3. The Board has continued to promote a transparent disciplinary process. What is NOT in dispute is that the hospital could have made barcode scanning technology a priority in radiology, given its high reliability for managing the risk of a competent, caring nurse showing up with the wrong drug in hand, as happened here. %PDF-1.6 % Nor did anyone consider if the nurse recognized the risk associated with talking to the orientee while pulling medications from the ADC at the time of the error. Disciplinary Action. Nurse retrieved a nonurgent medication from the ADC via override. License action type by Tennessee nursing professional. Suite 400, A nurse can be disciplined for "unprofessional conduct, and negligence, The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. x|83"n lNb:;U}#(jW5m?{8}q~;.>>vK}s[M^^\8_r%N){\~A9aH\9c$f#;_z5]m3g`utfpub>WdU_8WD,(Qs>qhD"63P22.3d|`zKA(%#PIA$1q?JwDU;G\-; If you are threatened with the loss of your professional license, you must take prompt action. July 13, 2020 Vaught's criminal trial is scheduled to begin. 2 0 obj Contact Info Georgia State Board. Available for institutions endobj Were they monitored and by whom and for how long? It is not our intent to embarrass or diminish the TNBoard of Nursing by pointing out what we find disturbing or unjust in the deliberations of this complex matter, but rather to find a better way to achieve justice, learning, and improvement in safety. Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign, and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm. a number of sources. However, RaDonda also testified that the error was made because of flawed procedures at the hospital, particularly the lack of timely communication between the pharmacy computer system and the ADC, which led to significant delays in accessing medications and the hospitals permission to temporarily override the ADC to obtain prescribed medications that were not yet linked to the patients profile in the ADC. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Information for health professionals regarding the COVID-19 response. Board of Nursing Complaint Process: Investigation to Resolution. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. stream See Table 1 for a more detailed timeline of events. ISMP believes the TN Board of Nursings disciplinary processes and judgment of RaDondas actions during this event are NOT aligned with the tenets of a Just Culture. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Any change to information is required to be reported within 30 days of the change. %PDF-1.7 I know the reason that this patient is no longer here is because of me. Unfortunately, the Board members seemed to interpret this only as a clear admission of guilt and did not appear to acknowledge the psychological pain RaDonda is still experiencing as a second victim of a fatal error. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Nurse administers IV vecuronium instead of Versed (midazolam). How to report patients abusing TennCare benefits. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Also, disciplinary sanctions are not imposed for at-risk behaviors, including not following the rules; any system design failures that may have contributed to not following the rules must be examined and factored into the judgment of the behavior. endobj There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. The professions that are required to submit information are: alcohol and drug abuse counselors, audiologists, certified nurse practitioners, chiropractors, clinical pastoral therapists, dentists, dietitian or nutritionists, dispensing opticians, electrologists, marital and family therapists, massage therapists, medical doctors, medical laboratory personnel, nursing home administrators, occupational therapists, optometrists, osteopathic physicians, pharmacists, physical therapists, physician assistants, podiatrists, professional counselors,psychologists, registered nurse anesthetists, respiratory care practitioners, social workers, speech pathologists and veterinarians. Filing Complaints and Researching Disciplinary Actions . ISMP was shocked, discouraged, and deeply saddened to learn that the Tennessee (TN) Board of Nursing recently revoked RaDonda Vaughts professional nursing license indefinitely, fined her $3,000, and stipulated that she pay up to $60,000 in prosecution costs. Yet, the primary way to determine the differences between at-risk and reckless behavior is to carefully consider the system-based causes that might have contributed to the behavioral choices. Name of Board: Tennessee Board of Nursing . Map & Directions [+]. The Division of Health Related Boards provides administrative support to the boards, committees, councils and one registry that are charged with the licensure and regulation of their respective health care professionals, as well as the Office of Consumer Right to Know. The prosecutor repeatedly referred to achieving the five rights of medication administration as good nursing practice and stated that, Minimally competent nursing practice requires that all five rights be followed. As presented, this appears to mean that nurses have a personal responsibility to produce the outcomes of the five rights, without error and irrespective of any system performance-shaping factors. Date of Meeting: May 1, 2023 . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Tennessee Department of Health Publications. To view your current profile, please go tohttp://apps.health.tn.gov/Licensure/Default.aspxand enter your license number and profession, then click on the Practitioner Profile link. The Office of Consumer Right to Know is charged with seeking and collecting this information and providing it to consumers via the Departments web site. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. Nashville, Please secure your User ID and Password for future use. Board of Nursing. Together the NPA and rules/regulations guide and govern nursing practice. Contact Info Montana State Board. Information Required to be Reported on Practitioner Profiles. Failure to consider the significant contribution of system failures. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. Nursysis the only national database for verification of nurse licensure, discipline and practice privileges for RNs,LPN/VNs and APRNs licensed in participating jurisdictions, including all states in theNurse Licensure Compact (NLC). Contact us with any comments or questions. hb```\^ !0!U[j|}+Iv0H/\K Below is a list of actions taken in July 2020. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. This timeline will help. %PDF-1.5 % Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Disciplinary action against her license was then filed. Late in 2018, the hospital was investigated by the Centers for Medicare & Medicaid Services (CMS) after an anonymous whistleblower came forward to report the fatal error. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Drug prescription errors, while serious events are not necessarily intentional. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. 1 0 obj Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Receive the monthly Disciplinary Action Report by e-mail. Misdemeanor convictions later expunged by a court of competent jurisdiction shall be stricken from the provider's profile; A description of any final board disciplinary actions within the most recent ten (10) years, which actions shall include final board action as defined by 4-5-314, and reprimand action taken pursuant to a board practice act; A description of any final disciplinary actions of licensing boards in other states within the most recent ten (10) years; A description of revocation or involuntary restrictions of hospital privileges for reasons related to competence or character that has been taken by the hospitals governing body or any other official action of the hospital after procedural due process has been afforded, or the resignation from or nonrenewal of medical staff membership or the restriction of privileges as a hospital taken in lieu of or in settlement or a pending disciplinary case related to competence or character in that hospital, all as taken pursuant to procedures promulgated by the board for licensing health care facilities. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Make a User ID that you can remember, such as your email address. NASHVILLE, Tenn. Tennessee Code Annotated, Section 68-- 1-114 requires the Tennessee - Department of Health to issue a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Information concerning all settlements shall be accompanied by the following statement: Settlement of a claim may occur for a variety of reasons which do not necessarily reflect negatively on the professional competence or conduct of the provider. Speak with an attorney as soon as possible. Undisputed failure but most likely human error, not reckless behavior. Nurse did not verify that the proper medication was administered to the patient. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. To cite another example, the prosecutor stated that a reasonable nurse would have seen that the ADC defaulted to searching by the generic drug name, not the brand name (which was difficult to notice at the time), rather than recognizing that the capability of the ADC to simultaneously search by brand and generic names would have been so much more effective. This information is not intended to create, and receipt endstream endobj startxref C. omplaints to nursing boards can come from . Information concerning paid medical malpractice claims shall be put in context by comparing an individual licensee's medical malpractice judgment awards and settlements to the experience of other providers within the same specialty. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Nurses criminal trial is scheduled to begin. The RaDonda Vaught case is confusing. If you applied for initial license online, you can use the same account to renew your license. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 13 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. Also, it cannot be asserted that the failure to document in the EHR contributed to the patients harm or denied her any opportunity for recovery. Also, the nurse was used to scanning the barcode on drug labels for verification and tried to locate a scanner to do so while in radiology, but to no availbarcode scanning technology was not available in radiology. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. Below is a list of actions taken in March 2021. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. TDH Newsroom. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws. hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 Below is a list of actions taken in NOVEMBER 2021. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. Investigation of the event did not include examination of recent sedation for claustrophobic patients in radiology or sedation with IV Versed to determine whether monitoring had occurred previously. As a primary source equivalent the data is provided directly from the boards of nursing. But mistakes were made. However, was the Boards action fair and just in this situation? When I started being a nurse, I told myself that I wanted to take care of people the way I would want my grandmother to be taken care of. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. %%EOF e-Notify Get free license expiration and status updates via email Disputed failure. Professional nursing license action report. NASHVILLE, Tenn. -- Tennessee Code Annotated, Section 68-1-114 requires the Tennessee Department of Health to issue a monthly media release listing all disciplinary actions taken by the health-related boards during the prior month. July 23, 2021. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. While the Board accepted the state prosecutors recommendation to revoke RaDondas nursing license, ISMP doubts that the Boards action was just, and we believe it set us back 25 years in patient safety. 466 0 obj <>stream By the time she arrived back in the intensive care unit (ICU), she learned of her error and immediately reported it and completed an event report. To determine what a reasonable nurse would do, the Board used a null hypothesis (suggesting no differences between nurses working in different systems) with a rigid lens in a vacuum, not actual nurses who were similarly situated, often leading to unreasonable expectations of a nurse. RaDonda was involved in a fatal medication error after entering ve in an automated dispensing cabinet (ADC) search field, accidentally removing a vial of vecuronium instead of VERSED (midazolam) from the cabinet via override, and unknowingly administering the neuromuscular blocking agent to the patient. As RaDondas defense attorney said during the hearing, Rather than revoking this good nurses license, there needs to be another way. If we dont find it, we risk jeopardizing the opportunity to recruit talented people into the healthcare fieldthey wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time.
Cary Benjamin Grant Photo,
What Does Psalm 36:6 Mean,
List Of Interesting Antonyms,
Atara Biotherapeutics Acquisition,
Articles T
tn board of nursing disciplinary actions