Disputed failure. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. 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. hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 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. 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 mission of each board is to safeguard the health, safety and welfare of . Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. In response to the whistleblower, CMS conducts a surprise hospital inspection. Click here to go to the live stream site. 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. . <> 0 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. Furthermore, the Board did not determine whether RaDonda saw the risk associated with her behavior as substantial and disregarded it, and whether her internal risk monitor firedthat little voice that creeps into our conscious thoughts and lets us know we are in danger. Nurse did not verify that the proper medication was administered to the patient. See what boards of nursing are currently participating. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. July 23, 2021. 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. 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. We believe this is what happened here. Date of Meeting: May 1, 2023 . 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 <> . 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. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. 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. Nurse failed to document vecuronium administration to the patient in the EHR. In a Just Culture, inadvertent behavior (human error) is not worthy of disciplinary sanction, regardless of the outcome, and the quality of behavioral choices made during an event are thoroughly examined to determine whether there was conscious disregard of significant risks. 7oM~/dc`xb7T206 )5F{w0Q ( 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. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. case or situation. 5200 Butler Pike Filing Complaints and Researching Disciplinary Actions . 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. 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. 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. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. Board of Nursing Complaint Process: Investigation to Resolution. 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. 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. For example, in the case of suspected theft or misappropriation, were there other professionals or employees present who had access to the alleged misappropriated items? Board of Nursing. 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. RaDonda's criminal trial is scheduled to begin on . 1419 0 obj <>/Filter/FlateDecode/ID[<7C1E6885F79A2840B3CD3D4380937611><607411345D04C24E89F3B328005C117C>]/Index[1406 27]/Info 1405 0 R/Length 73/Prev 82019/Root 1407 0 R/Size 1433/Type/XRef/W[1 2 1]>>stream 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. This information is not intended to create, and receipt 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. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 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. Table 2. 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. Contact us with any comments or questions. 63-7-115. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. The Administrative Procedures Division is the administrative court for the State. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. Comprehensive information on protecting one's . (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. Take disciplinary actions as necessary to protect the public from unsafe nurses. endobj Nurses alleged failures and unanswered questions about the event. (2) In order to be issued a certificate of fitness as a nurse practitioner with . 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. Contact Info Georgia State Board. Nurse administers IV vecuronium instead of Versed (midazolam). Please include your name, title/position, organization name, office phone and email in your request. Board revokes the nurses professional license and fines her $3,000. Complaints. 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). 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. Time: 1:00 p.m. C.T. Suite 400 Currently, the annual rate of discipline on a nursing license is less than one percent. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. Below is a list of actions taken in March 2021. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. <>/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>> Please include your name, title/position, organization name, office phone and . Institute for Safe MedicationPractices 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. hb```\^ !0!U[j|}+Iv0H/\K endstream endobj startxref 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. Contact the board at (615) 532-5166. 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. %PDF-1.5 % The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. Information Required to be Reported on Practitioner Profiles. 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. 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. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. 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. 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. Patient involved in medication error is withdrawn from life support and dies. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. Were they monitored and by whom and for how long? Nurse did not verify that the proper medication was removed from the ADC. Disciplinary action against her license was then filed. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. 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. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Together the NPA and rules/regulations guide and govern nursing practice. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. Discipline Meeting . Fifty states, District of Columbia and 4 United States (US) territories . This page has information and updates on nursing boards and regulation specific to Georgia. Make a User ID that you can remember, such as your email address. Undisputed failure but most likely at-risk, not reckless, behavior. Place: Electronic Meeting / Poplar Room . National Council of State Boards of Nursing, Inc. All Rights Reserved. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . 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. While the Board believed it was conscious disregard to not read the label, this is likely human error, as it happened inadvertently when she saw that the drug was a powder and quickly turned the vial over. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Inability to differentiate between human error, at-risk behavior, and reckless behavior. 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. or viewing does not constitute, an attorney-client relationship. TN Speak with an attorney as soon as possible. %PDF-1.7 Nursing Licensure for Internationally Educated Nurses, See what boards of nursing are currently participating, Enhance communication between member boards, Retrieve discipline and various other reports. % .`jh L@ b But mistakes were made. The court for Tennessee professional licensing is the Administrative Procedures Division. The information on this website is for general information purposes only. 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. If you applied for initial license online, you can use the same account to renew your license. Nursys is the only national nurse licensure and disciplinary database. 466 0 obj <>stream 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. 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. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. Find Your Nurse Practice Act. In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. 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. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. endobj In the end, the prosecutor made the statement that, Nothing [the hospital] could have done would have made the respondent [RaDonda] meet the standards of nursing practice She admitted to alarm and warning fatigue. 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. The nurses license verification is available immediately to the endorsing board of nursing. Detailed information about disciplinary . Listed below are the meetings held for the past year. Undisputed failure but most likely human error, not reckless behavior. Nurse charged with criminal reckless homicide and impaired adult abuse. Any change to information is required to be reported within 30 days of the change. Map & Directions [+]. Receive the monthly Disciplinary Action Report by e-mail. 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. 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. Please secure your User ID and Password for future use. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. 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. Read our recipe for investigating nursing boards' oversight . The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . 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? You must be logged in to view and download this document. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Hospital fires nurse for not following the five rights of medication administration. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. Professional nursing license action report. TDH Newsroom. Contact Info Montana State Board. Filing Complaints and Researching Disciplinary Actions. License action type by Tennessee nursing professional. and nurses. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. Board members, with few exceptions, are appointed by the Governor. 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. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. endstream endobj startxref You must have JavaScript enabled to use this form. Monday, May 1, 2023 . Nashville Tennessean. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. The state's duty to protect those who receive nursing care is the basis for a nursing license. %PDF-1.6 % The nurse was surprised that the medication was a powder, so she turned the vial over quickly to look at the reconstitution directions on the back of the label, without looking at the front of the label (and product name). The court for Tennessee professional licensing is the Administrative Procedures Division. 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. Receive the monthly Disciplinary Action Report bye-mail. To SEARCH and find an individual, press Control and 'f' keys, and type in name. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. Read our recipe for investigating nursing boards' oversight . e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. These laws are defined in the Nursing Practice Act (NPA). Adapted from: Kelman B. Nurse retrieved a nonurgent medication from the ADC via override. 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. 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. 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. 1 0 obj National Council of State Boards of Nursing, Inc. All Rights Reserved. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. The Board has continued to promote a transparent disciplinary process. The same Board member said a reasonable nurse would have brought appropriate monitoring equipment and oxygen to radiology to monitor the patient, despite repeated discussions with the primary care nurse who explicitly noted that no monitoring was required. This timeline will help. She said through tears at the hearing, I wont ever be the same person. The RaDonda Vaught case is confusing. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Failure to consider the significant contribution of system failures. 1432 0 obj <>stream 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. 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. 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. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. 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 . 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. She did not read the front of the medication label due to either a momentary distraction (error) or an unsafe practice habit (at-risk behavior). 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. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . 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. 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. Without your 214 2nd Avenue N. 3 0 obj While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. 0 To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. 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. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. If you are threatened with the loss of your professional license, you must take prompt action. Disciplinary Action. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. Tennessee Department of Health Publications. DISCIPLINARY ACTION REPORT . The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Detailed information about disciplinary actions is available on . In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . `g"H>O|oD)svT>VZ9,VP{PVy9[K. 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. 2 0 obj 1406 0 obj <> endobj Disciplinary Action Report Page 1 of 11 . 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. However, this failure is substantively unimportant relative to the wrong drug error. 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. 4 0 obj Didn't find what you are looking for? Select Begin Here For Sign-up under New User to create your account.

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