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. Adapted from: Kelman B. She said through tears at the hearing, I wont ever be the same person. hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 RaDondas criminal trial is scheduled to begin on March 21, 2022. Receive the monthly Disciplinary Action Report bye-mail. The court for Tennessee professional licensing is the Administrative Procedures Division. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. (2) In order to be issued a certificate of fitness as a nurse practitioner with . Please secure your User ID and Password for future use. Undisputed failure but most likely at-risk, not reckless, behavior. Find Your Nurse Practice Act | NCSBN Georgia: Nursing Board Tracker - ProPublica Listed below are the meetings held for the past year. Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. 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! 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. 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. Time: 1:00 p.m. C.T. Monday, May 1, 2023 . 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. Nurse did not verify that the proper medication was removed from the ADC. PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. What Discipline Can a Board of Nursing Impose Against a Nurse Licensee Undisputed failure but most likely human error, not reckless behavior. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. Nurses criminal trial is scheduled to begin. 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. Patient involved in medication error is withdrawn from life support and dies. Lack of a thorough investigation. 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. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. case or situation. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. Select Begin Here For Sign-up under New User to create your account. 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. hbbd``b`:$gP " `v nb-W&FV^ 'F 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). Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . Below is a list of actions taken in March 2021. 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. 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. Board of Nursing Complaint Process: Investigation to Resolution. 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? Contact Info Georgia State Board. 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. Disciplinary Action. PDF Tennessee Department of Health Health Related Boards Memorandum The Administrative Procedures Division is the administrative court for the State. 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. 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. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Below is a list of actions taken in July 2020. 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. 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. The RaDonda Vaught case is confusing. 37201 Detailed information about disciplinary actions is available on . To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. 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. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. Request monthly Disciplinary Action Report by e-mail. Nashville Tennessean. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ 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. e-Notify Get free license expiration and status updates via email Discipline Meeting . These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 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. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. Didn't find what you are looking for? 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. 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. 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. 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). <> 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. Hospital settles with patients family, requiring them to not speak about the error publicly. Please include your name, title/position, organization name, office phone and . In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . 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. 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. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. Information for health professionals regarding the COVID-19 response. Undisputed failure. 3 0 obj By the time she arrived back in the intensive care unit (ICU), she learned of her error and immediately reported it and completed an event report. To determine what a reasonable nurse would do, the Board used a null hypothesis (suggesting no differences between nurses working in different systems) with a rigid lens in a vacuum, not actual nurses who were similarly situated, often leading to unreasonable expectations of a nurse. Complaints - Tennessee Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . 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. Virginia Board of Nursing - Disciplinary Proceedings News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Survey of Advanced Practice Registered Nurses Disciplinary Action % Map & Directions [+]. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. 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. 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. 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, Every state and territory in the US set laws to govern the practice of nursing. 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. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. 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. Board members, with few exceptions, are appointed by the Governor. 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 patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Comprehensive information on protecting one's . 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. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. %%EOF July 23, 2021. Suite 400, Complaints. Nurse did not verify that the proper medication was administered to the patient. 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. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. TN However, was the Boards action fair and just in this situation? In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. . Click here to go to the live stream site. This timeline will help. PDF Disciplinary Action Report Page 1 of 18 - Tennessee 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. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Nurses alleged failures and unanswered questions about the event. 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). Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Find Your Nurse Practice Act. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv 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. 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. For Institutions. 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 Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Table 2. If you applied for initial license online, you can use the same account to renew your license. 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. 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. Nurse administers IV vecuronium instead of Versed (midazolam). 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. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. RaDonda's criminal trial is scheduled to begin on . Please include your name, title/position, organization name, office phone and email in your request. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. If you are threatened with the loss of your professional license, you must take prompt action. Look up, verify and monitor your nurse licenses anytime, anywhere. 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. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". PDF Rules of The Tennessee Board of Nursing Chapter 1000-04 Advanced PDF Disciplinary Action Report Page 1 of 14 - Tennessee 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. TDH Newsroom. Together the NPA and rules/regulations guide and govern nursing practice. As a primary source equivalent the data is provided directly from the boards of nursing.