"9$3. 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. 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. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. Drug prescription errors, while serious events are not necessarily intentional. @3Mh?d+Nu*%5l(U9{rRA>@l=ph 2023 Institute for Safe Medication Practices. 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. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. 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. These laws are defined in the Nursing Practice Act (NPA). Patient involved in medication error is withdrawn from life support and dies. Consequences range from moderate to severe, including permanent license revocation and significant fines: In certain areas, such as alleged chart falsification or chart illegibility, the Tennessee Board of Nursing presumes the nursing professional acted with intent. In cases of this type, a nursing professional's legal counsel may get a dismissal or reduction of charges by exposing weaknesses in the board's case. Each provider licensing board shall set by rule adopted pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, a threshold amount below which judgments or settlements shall not be reportable; provided, such threshold shall, for chapter 6 or 9 of this title licensees, be set at seventy-five thousand dollars ($75,000), for doctors of chiropractic, regulated pursuant to chapter 4 of this title, be set at fifty thousand dollars ($50,000), for dentists, regulated pursuant to chapter 5 of this title, be set at twenty-five thousand dollars ($25,000), and for all other licensees under this title be set at ten thousand dollars ($10,000). The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. If allegations against a nurse are proven, or he or she admits to the allegations, a board of nursing has the authority to discipline the nurse. Projectionsbased on a single month, while not statistically accurate, suggest a large number of annual nursing license disciplinary actions may result from controlled substance issues. Board of Nursing. Undisputed failure but most likely at-risk, not reckless, behavior. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Nurses disciplinary licensing hearing is held. License action type by Tennessee nursing professional. A payment in settlement of a medical malpractice action or claim should not be construed as creating a presumption that medical malpractice has occurred. (Pending malpractice claims shall not be disclosed by a board to the public. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. 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. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. Date of Meeting: May 1, 2023 . The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. endobj But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Available for institutions Nurse failed to document vecuronium administration to the patient in the EHR. Serious Disciplinary Actions States. Filing Complaints and Researching Disciplinary Actions . RaDonda's criminal trial is scheduled to begin on . While nursing mistakes or misconduct may lead to other consequences, such as employer reprimands, terminations, civil suits, or criminal charges, nurse disciplinary action directly affects a nurse's license. Nashville, TN 37201. 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. Nursys is the only national nurse licensure and disciplinary database. You must have JavaScript enabled to use this form. %%EOF The Board has continued to promote a transparent disciplinary process. and nurses. case or situation. Map & Directions [+]. Find Your Nurse Practice Act. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. Information Required to be Reported on Practitioner Profiles. Table 2. You must be logged in to view and download this document. The RaDonda Vaught case is confusing. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Undisputed failure. 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. Hospital fires nurse for not following the five rights of medication administration. Disciplinary Action Report Page 1 of 11 . 0 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. 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. Below is a list of actions taken in July 2020. Lack of a thorough investigation. 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. Disciplinary hearings are conducted in accordance with the "Open Meetings Act" NMSA 1978, Chapter 10, Article 15 and all disciplinary actions are listed on the Board website and published in the Board newsletter quarterly. {dhF`g)Ut9`6XX:WaVUR!@Z! The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. 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. 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. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. DISCIPLINARY 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. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv 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. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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. Below is a list of actions taken in NOVEMBER 2021. The state's duty to protect those who receive nursing care is the basis for a nursing license. 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. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. 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" 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. Undisputed failure but most likely human error, not reckless behavior. 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. However, was the Boards action fair and just in this situation? `g"H>O|oD)svT>VZ9,VP{PVy9[K. July 23, 2021. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. The information on this website is for general information purposes only. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. 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. Registered Nurse Licensed Practical Nurse Clinical Nursing Specialist Nurse Practitioner Contact: Sylvia Tamayo-Suijk, (804) 367-4502 , sylvia.tamayo-suijk@dhp.virginia.gov For: Nurse Aide Medication Aide Licensed Massage Therapist Contact: Cathy Hanchey, ( 804)367-4481 , cathy.hanchey@dhp.virginia.gov Virginia Board of Nursing Nurses criminal trial is scheduled to begin. 1:00 p.m. Call to Order Board Meeting A nurse can be disciplined for "unprofessional conduct, and negligence, 4 0 obj 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. Discipline Meeting . 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. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. 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. %PDF-1.7 See what boards of nursing are currently participating. Look up, verify and monitor your nurse licenses anytime, anywhere. Read our recipe for investigating nursing boards' oversight . Nashville Tennessean. DISCIPLINARY ACTION REPORT . 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. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Request monthly Disciplinary Action Report by e-mail. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. Accountability for not following the five rights. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. Nurses alleged failures and unanswered questions about the event. This page has information and updates on nursing boards and regulation specific to Georgia. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. 1 0 obj Nurse did not verify that the proper medication was removed from the ADC. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. TN 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. 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. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. If it was a choice to not read the front of the label, at worse, it would be an at-risk behavior since most decisions are made on the fly in the subconscious, without the risk monitor firing. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. Please secure your User ID and Password for future use. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. 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. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. 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. 457 0 obj <>/Filter/FlateDecode/ID[<4E10B6721FA6774B905977532A094C83><1EEB8E14ED3DC44691B1AA4AE180590B>]/Index[437 30]/Info 436 0 R/Length 99/Prev 185930/Root 438 0 R/Size 467/Type/XRef/W[1 3 1]>>stream (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . 2 0 obj Nothing on this site should be taken as legal advice for any individual 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. Disciplinary action against her license was then filed. The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing. As a primary source equivalent the data is provided directly from the boards of nursing. <> 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. The nurses license verification is available immediately to the endorsing board of nursing. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. However, this failure is substantively unimportant relative to the wrong drug error. For Institutions. Nurse charged with criminal reckless homicide and impaired adult abuse. Although many questions regarding RaDondas alleged failures and the event remain unanswered (Table 2), the Board still voted unanimously to strip RaDonda of her nursing license and levy the full monetary penalties allowed, noting that there were just too many red flags that RaDonda ignored when administering the medication. As ISMP knows well from the vast number of error reports received, even the most careful and competent practitioner might make these mistakes or drift into unsafe practice habits without recognizing the risks. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. The number of license violations per category for November 2018 are listed below: Nursing professionals in Tennessee who are threatened with the loss of their licenses can take action to protect their licenses. 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. On September 27, 2019, in a stark reversal of a 2018 decision to take no licensing action against the nurse, the TN Board of Nursing filed disciplinary action against RaDonda that focused on three violations: Unprofessional conduct related to nursing practice and the five rights of medication administration, Abandoning or neglecting a patient requiring nursing care, Failure to maintain a record of interventions. Any change to information is required to be reported within 30 days of the change. 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 . Read our recipe for investigating nursing boards' oversight . 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! While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. 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, Board of Nursing Complaint Process: Investigation to Resolution. 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. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. endstream endobj startxref The court for Tennessee professional licensing is the Administrative Procedures Division. %%EOF 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. 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. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. nunsirg ce nli es. 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. Place: Electronic Meeting / Poplar Room . Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. hb```\^ !0!U[j|}+Iv0H/\K Were they monitored and by whom and for how long? Nurses disciplinary hearing is scheduled but delayed due to the pandemic. RaDondas criminal trial is scheduled to begin on March 21, 2022. a number of sources. National Council of State Boards of Nursing, Inc. All Rights Reserved. %PDF-1.6 % 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. Disputed failure. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> or viewing does not constitute, an attorney-client relationship. Disciplinary Action. Receive the monthly Disciplinary Action Report by e-mail. RaDonda could not have consciously disregarded a substantial and unjustifiable riska requirement for reckless behaviorbecause she had no idea that she had made a mistake. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. 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. 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. 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. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. 3 0 obj 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. Detailed information about disciplinary actions is available on . Every state and territory in the US set laws to govern the practice of nursing. 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. Nurse did not verify that the proper medication was administered to the patient. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. U.S. 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.

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