tn board of nursing disciplinary actionsinstall cloudready on android tablet

Nashville Tennessean. Nursing Disciplinary Process in Tennessee SURBER, ASHER, SURBER & MOUSHON, PLLC WWW.TENNLAWFIRM.COM (615)997-1914 6 Grounds for Disciplinary Action Rules of the Tennessee Board of Nursing describe the Standards of Nursing Conduct or Practice. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Undisputed failure but most likely at-risk, not reckless, behavior. July 23, 2021. 0 Nurse did not verify that the proper medication was removed from the ADC. A payment in settlement of a medical malpractice action or claim should not be construed as creating a presumption that medical malpractice has occurred. (Pending malpractice claims shall not be disclosed by a board to the public. Contact Info Georgia State Board. Board revokes the nurses professional license and fines her $3,000. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Information Required to be Reported on Practitioner Profiles. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. Please include your name, title/position, organization name, office phone and . Nurses alleged failures and unanswered questions about the event. However, this failure is substantively unimportant relative to the wrong drug error. Disciplinary Actions by the Tennessee Board of Nursing, License revoked: LPN = 2, CNA = 5, RN = 11, License suspended: LPN = 1, CNA = 0, RN = 14, License probation: LPN = 0, CNA = 0, RN = 15, License reprimanded: LPN = 0, CNA = 0, RN = 3, 23 Drug abuse, including over-prescribing or illegal prescriptions, 02 Patient chart falsification or patient chart data recorded illegibly, 02 Drug addiction, including substance addictionor substance use on duty, 19 Incompetence, negligence or unprofessional conduct. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Disciplinary Action. For Institutions. endstream endobj startxref Without your 214 2nd Avenue N. 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. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. The mission of each board is to safeguard the health, safety and welfare of . "9$3. And while RaDonda made a conscious decision to not monitor the patient or scan the medications barcode, she was told that monitoring was not required, and barcode scanning technology was not available in radiology. Also, hospital policy did not require monitoring after Versed administration, and the drug was not mentioned in the moderate sedation policy or the hospitals high-alert medication list. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Select Begin Here For Sign-up under New User to create your account. If you applied for initial license online, you can use the same account to renew your license. 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. Nashville, TN 37201. 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. and nurses. . e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. {dhF`g)Ut9`6XX:WaVUR!@Z! 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. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. 1406 0 obj <> endobj The prosecutor acknowledged that the hospital had various system failures that contributed to the error; however, he stressed that the Board is not here to look at the system and is instead looking at individual conduct. Thus, the Board judged RaDondas behavior in isolation of the contributing system failures. If the after a thorough investigation, the BON determines there is sufficient basis that the nurse violated the act or regulations, the BON may take disciplinary action on the nurses license. Filing Complaints and Researching Disciplinary Actions. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. In response to the whistleblower, CMS conducts a surprise hospital inspection. Please click the link below to access the licensure renewal page. 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. Development of Sanctioning Guidelines for Public Discipline in Nursing Regulation: The North Carolina Board of Nursing Journey; What Could Happen: The Consequences of "Practice Drift" Dispositions of paid claims shall be reported in a minimum of three (3) graduated categories indicating the level of significance of the award or settlement. Only cases that have occurred within the most recent ten (10) years shall be disclosed by the department to the public; All medical malpractice court judgments, all medical malpractice arbitration awards in which a payment is awarded to a complaining party and all settlements of medical malpractice claims in which a payment is made to a complaining party beginning with reports for 1998 and each subsequent year; provided, such reports shall not be disseminated beyond the most recent ten-year period, but shall include the most recent ten-year period for which reports have been filed. 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. Disputed failure. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Yet, a failure to follow the five rights is often cited as a performance deficit when a medication error occurs, clearly perpetuating the mistaken belief that healthcare practitioners can be held individually accountable for achieving these goals. (2) In order to be issued a certificate of fitness as a nurse practitioner with . Nurses alleged failures and unanswered questions about the event, anonymous whistleblower came forward to report the fatal error, TN Board of Nursing filed disciplinary action, crisis experienced by second victims of fatal errors, Anonymous whistleblower alerts state/federal agencies, Department of Health (Nursing Board) decides not to pursue disciplinary action, Department of Health (Nursing Board) reverses its prior decision, The RaDonda Vaught case is confusing. In fact, the Board has not filed disciplinary action against all TN nurses who have not read a medication label carefully, obtained a nonurgent medication from an ADC via override, drawn an incorrect conclusion, failed to monitor a sedated patient, or failed to document a medication error in the patients record. An outcome bias often results in over-reacting to a singular event with unwarranted disciplinary action, or under-reacting to a system design flaw if the outcome is not harmful. Take disciplinary actions as necessary to protect the public from unsafe nurses. In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. 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. Please include your name, title/position, organization name, office phone and email in your request. Below is a list of actions taken in July 2020. Projectionsbased on a single month, while not statistically accurate, suggest a large number of annual nursing license disciplinary actions may result from controlled substance issues. 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. The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. This timeline will help, Medication Safety Officers Society (MSOS). 1 0 obj Drug prescription errors, while serious events are not necessarily intentional. Information concerning paid medical malpractice claims shall be put in context by comparing an individual licensee's medical malpractice judgment awards and settlements to the experience of other providers within the same specialty. The professions required to submit and maintain a practitioner profile questionnaire are: Tennessee Code Annotated Title 63 Chapter 51 requires the following information to be reported to the Board for dissemination to the public on practitioner profiles: http://apps.health.tn.gov/Licensure/Default.aspx, Tennessee Department of Health Publications, Licensed Registered Respiratory Therapists, Licensed Certified Respiratory Therapists. More warnings would not have changed her performance.. Nurse failed to document vecuronium administration to the patient in the EHR. This page has information and updates on nursing boards and regulation specific to Montana. The RaDonda Vaught case is confusing. Contact the board at (615) 532-5166. You must be logged in to view and download this document. x|83"n lNb:;U}#(jW5m?{8}q~;.>>vK}s[M^^\8_r%N){\~A9aH\9c$f#;_z5]m3g`utfpub>WdU_8WD,(Qs>qhD"63P22.3d|`zKA(%#PIA$1q?JwDU;G\-; Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. hb```\^ !0!U[j|}+Iv0H/\K In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 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. <>/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>> The board of nursing (BON), through its statutory authority specified in the nurse practice act, is responsible for reviewing and acting on complaints in order to fulfill their mission to protect the public. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. However, was the Boards action fair and just in this situation? 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. 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. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Nurses can verify their licenses by completing the Nursys verification process for $30 per license type, per each board of nursing where the nurse is applying. The Administrative Procedures Division is the administrative court for the State. Also, disciplinary sanctions are not imposed for at-risk behaviors, including not following the rules; any system design failures that may have contributed to not following the rules must be examined and factored into the judgment of the behavior. This information is not intended to create, and receipt To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Read our recipe for investigating nursing boards' oversight . Nashville, Please secure your User ID and Password for future use. For example, the Board considered neuromuscular blocking agent warnings on the ADC screen and shrink wrap sleeves over the vials to be red flags overlooked by RaDonda, when both had been added to improve the warning system after the event occurred. Serious Disciplinary Actions States. The Board has continued to promote a transparent disciplinary process. `g"H>O|oD)svT>VZ9,VP{PVy9[K. Lack of a thorough investigation. While the Board accepted the state prosecutors recommendation to revoke RaDondas nursing license, ISMP doubts that the Boards action was just, and we believe it set us back 25 years in patient safety. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. The state's duty to protect those who receive nursing care is the basis for a nursing license. endstream endobj 1407 0 obj <. Make a User ID that you can remember, such as your email address. 1432 0 obj <>stream Contact Info Montana State Board. 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. 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. 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. 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. .`jh L@ b Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. See what boards of nursing are currently participating. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. Nurse claims that after failing to find the order in the patients profile in the ADC, she called the charge nurse to make sure the order had been placed, and then entered an empty room and checked the patients electronic health record (EHR) to verify the physicians order before returning to the ADC to withdraw the drug via override. Plymouth Meeting, PA 19462. Below is a list of actions taken in March 2021. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. The nurse believed she administered the prescribed dose of 1 mg (which was actually vecuronium, not Versed) after reading the directions for reconstitution on the label, correctly reconstituting the drug, and administering 1 mL of the reconstituted drug. Believing the best in everyone, ISMP has faith that the TN Board of Nursing likely had the right, albeit misguided, intention to protect the citizens of TN. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Table 2. stream here are three Nursys services publicly available via nursys.com: e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Detailed information about disciplinary actions is available on . Patients, coworkers, members of the public, or employers can call the board of nursing, put complaints in writing, or complete a board of nursing Web site complaint form. While searching for information on a particular health care professional, consumers should be aware that there are several locations available to aid them with their research. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Undisputed failure. %%EOF Discipline was defined as a formal action taken by a board of nursing or a court, whereby an APRN received a formal letter of reprimand, a restriction placed on an active license or certification, such as a prohibition against narcotic access, restriction from participating in the multi-state licensure compact, suspension with or without a stay, 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. 3 0 obj Below is a list of actions taken in NOVEMBER 2021. RaDondas criminal trial is scheduled to begin on March 21, 2022. July 13, 2020 Vaught's criminal trial is scheduled to begin. Information for health professionals regarding the COVID-19 response. endobj Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Contact us with any comments or questions. See Table 1 for a more detailed timeline of events. 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. Accountability for not following the five rights. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . Failure to recognize self-blame in second victims. During the hearing, RaDonda appeared to fall on the sword of guilt, remorse, self-doubt, loss of confidence, and a wish to make amends. Disputed failure. Discipline Meeting . 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. Institute for Safe MedicationPractices National Council of State Boards of Nursing, Inc. All Rights Reserved. Disputed failure. 214 2nd Avenue N., endobj But the five rights are merely broadly stated goals or desired outcomes of safe medication practices that offer no procedural guidance on how to achieve these goals. . You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). Suite 400 Complaints. 0 Patient involved in medication error is withdrawn from life support and dies. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Place: Electronic Meeting / Poplar Room . The mission of each board is to safeguard the health, safety and welfare of Tennesseans by requiring those who practice health care professions within this state to be qualified. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. You can draw your own conclusions by viewing the 2-day hearing, but the following is what ISMP finds most disturbing and unjust about the Boards decision to revoke RaDondas license: Significant outcome bias. or viewing does not constitute, an attorney-client relationship. Any actions taken by the boards must be filed with the Administrative Procedures Division of the Secretary of States Office in which effective dates will be assigned. Look up, verify and monitor your nurse licenses anytime, anywhere. Getting to Know Your Licensing Board: the North Carolina Board of Nursing at a Glance; What Nurses need to know about Informatics, Social Media, and Security! The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. %PDF-1.5 % After discussions on this topic, the nurse did not think she had a duty to monitor the patient. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Request monthly Disciplinary Action Report by e-mail. Nurse did not verify that the proper medication was administered to the patient. We believe this is what happened here. Receive the monthly Disciplinary Action Report by e-mail. Disciplinary action taken by the institution or organization if action pertains to the Board's grounds for disciplinary action (see related content below) Minnesota Statutes Section 148.261 . Map & Directions [+]. % Disciplinary Action Report Page 1 of 11 . Any change to information is required to be reported within 30 days of the change. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. Professional nursing license action report. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. Nurse could not carry out the physicians order to repeat the first dose if insufficient because she did not monitor the effectiveness of the first dose. Failure to consider the significant contribution of system failures. 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. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. Disciplinary action against her license was then filed. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Adapted from: Kelman B. Undisputed failure but most likely at-risk, not reckless, behavior. 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. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. 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. Board of Nursing. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Board actions may include: Fine or civil penalty. Nurses disciplinary licensing hearing is held. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 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. case or situation. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. ); 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). 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. The court for Tennessee professional licensing is the Administrative Procedures Division. 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. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. %%EOF The nurses license verification is available immediately to the endorsing board of nursing. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. 37201 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. 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. These laws are defined in the Nursing Practice Act (NPA). Currently, the annual rate of discipline on a nursing license is less than one percent. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. endstream endobj startxref %PDF-1.6 % TDH Newsroom. Receive the monthly Disciplinary Action Report bye-mail. When an individual is engaged in at-risk behavior, their internal risk monitor is silent.

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