Board members, with few exceptions, are appointed by the Governor. The information on this website is for general information purposes only. 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. Any change to information is required to be reported within 30 days of the change. 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. Hospital fires nurse for not following the five rights of medication administration. The nurses license verification is available immediately to the endorsing board of nursing. Nurse did not verify that the proper medication was removed from the ADC. Nursys is the only national nurse licensure and disciplinary database. 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 Nurse retrieved a nonurgent medication from the ADC via override. National Council of State Boards of Nursing, Inc. All Rights Reserved. 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. 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. Undisputed failure but most likely at-risk, not reckless, behavior. 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. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. Look up, verify and monitor your nurse licenses anytime, anywhere. 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 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. Discipline Meeting . These laws are defined in the Nursing Practice Act (NPA). 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. RaDonda's criminal trial is scheduled to begin on . The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. TDH Newsroom. 2 0 obj Contact us with any comments or questions. (2) In order to be issued a certificate of fitness as a nurse practitioner with . A nurse can be disciplined for "unprofessional conduct, and negligence, Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. Take disciplinary actions as necessary to protect the public from unsafe nurses. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . 7oM~/dc`xb7T206 )5F{w0Q ( 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. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Receive the monthly Disciplinary Action Report bye-mail. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. Disciplinary action against her license was then filed. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. 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). 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 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. Nurses alleged failures and unanswered questions about the event. nunsirg ce nli es. Disciplinary Action Report Page 1 of 11 . She said through tears at the hearing, I wont ever be the same person. Unreasonable expectations. 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. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! 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. 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? Information Required to be Reported on Practitioner Profiles. 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. 214 2nd Avenue N., 1406 0 obj <> endobj The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Drug prescription errors, while serious events are not necessarily intentional. 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\-; You must be logged in to view and download this document. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. 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. Nurses criminal trial is scheduled to begin. Accountability for not following the five rights. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. 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" The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. 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. 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. 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. Disputed failure. Serious Disciplinary Actions States. 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. C. omplaints to nursing boards can come from . 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. 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. 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 state's duty to protect those who receive nursing care is the basis for a nursing license. Below is a list of actions taken in March 2021. License action type by Tennessee nursing professional. Request monthly Disciplinary Action Report by e-mail. Please secure your User ID and Password for future use. Professional nursing license action report. 437 0 obj <> endobj case or situation. Were they monitored and by whom and for how long? The RaDonda Vaught case is confusing. 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, Make a User ID that you can remember, such as your email address. Below is a list of actions taken in NOVEMBER 2021. 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. 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 timeline will help, Medication Safety Officers Society (MSOS). 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. a number of sources. Comprehensive information on protecting one's . Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. 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. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. Nurse did not verify that the proper medication was administered to the patient. .`jh L@ b 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? and nurses. Disciplinary action against her license was then filed. Plymouth Meeting, PA 19462. The boards interpret the laws, rules and regulations to determine the appropriate standards of practice in an effort to ensure the highest degree of professional conduct. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. or viewing does not constitute, an attorney-client relationship. 0 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. 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. If you are threatened with the loss of your professional license, you must take prompt action. The standards are very broad. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. Place: Electronic Meeting / Poplar Room . 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). After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. 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. Inability to differentiate between human error, at-risk behavior, and reckless behavior. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv Undisputed failure but most likely human error, not reckless behavior. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. This page has information and updates on nursing boards and regulation specific to Montana. 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. 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. Receive the monthly Disciplinary Action Report by e-mail. The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. 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. Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . Below is a list of actions taken in July 2020. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. All rights reserved. Nothing on this site should be taken as legal advice for any individual And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. 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. Board of Nursing Complaint Process: Investigation to Resolution. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. How to report patients abusing TennCare benefits. 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. `g"H>O|oD)svT>VZ9,VP{PVy9[K. Filing Complaints and Researching Disciplinary Actions. Suite 400, We believe this is what happened here. 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. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Detailed information about disciplinary actions is available on . Read our recipe for investigating nursing boards' oversight . Patient involved in medication error is withdrawn from life support and dies. 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. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Institute for Safe MedicationPractices Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. Undisputed failure. 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. Undisputed failure but most likely at-risk, not reckless, behavior. Click here to go to the live stream site. Hospital settles with patients family, requiring them to not speak about the error publicly. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Time: 1:00 p.m. C.T. 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. More warnings would not have changed her performance.. Please click the link below to access the licensure renewal page. Board of Nursing. endstream endobj startxref Name of Board: Tennessee Board of Nursing . There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Suite 400 %PDF-1.5 % May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. 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. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. This timeline will help. 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. 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. 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.