tn board of nursing disciplinary actionstn board of nursing disciplinary actions

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. 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. Look up, verify and monitor your nurse licenses anytime, anywhere. July 13, 2020 Vaught's criminal trial is scheduled to begin. 1432 0 obj <>stream 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. Serious Disciplinary Actions States. 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. 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. 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. You must be logged in to view and download this document. Disciplinary Actions Taken by the Board - Oregon Nurse did not verify that the proper medication was administered to the patient. Failure to consider the significant contribution of system failures. case or situation. Discipline Meeting . 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. National Council of State Boards of Nursing, Inc. All Rights Reserved. Below is a list of actions taken in NOVEMBER 2021. Nurse retrieved a nonurgent medication from the ADC via override. Make a User ID that you can remember, such as your email address. Disputed failure. PDF Professional Licensure: Investigation and Disciplinary Action Disputed failure. 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? 63-7-115. endobj Practitioner Profiles - Tennessee 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. 5200 Butler Pike 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 . What Discipline Can a Board of Nursing Impose Against a Nurse Licensee 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. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. 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. Every state and territory in the US set laws to govern the practice of nursing. See Table 1 for a more detailed timeline of events. The standards are very broad. 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. Undisputed failure but most likely human error, not reckless behavior. PDF Tennessee Department of Health Health Related Boards Memorandum The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". But mistakes were made. Adapted from: Kelman B. 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). How to report patients abusing TennCare benefits. 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. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. 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. 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. . 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. 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. Request monthly Disciplinary Action Report by e-mail. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. 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. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Nashville, TN 37201. "9$3. RaDonda was involved in a fatal medication error after entering ve in an automated dispensing cabinet (ADC) search field, accidentally removing a vial of vecuronium instead of VERSED (midazolam) from the cabinet via override, and unknowingly administering the neuromuscular blocking agent to the patient. The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. Yet, a failure to follow the five rights is often cited as a performance deficit when a medication error occurs, clearly perpetuating the mistaken belief that healthcare practitioners can be held individually accountable for achieving these goals. Monday, May 1, 2023 . To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Listed below are the meetings held for the past year. x|83"n lNb:;U}#(jW5m?{8}q~;.>>vK}s[M^^\8_r%N){\~A9aH\9c$f#;_z5]m3g`utfpub>WdU_8WD,(Qs>qhD"63P22.3d|`zKA(%#PIA$1q?JwDU;G\-; ); Names of medical schools or professional and training schools and dates of graduation; Graduate medical education or other graduate-level training; Specialty board certification as determined by the relevant board; Names of the hospitals where the licensee has privileges; The identification of any translating services that may be available at the licensee's primary practice location; An indication of which managed care plans in which the licensee participates; An indication of TennCare plans in which the licensee participates; Appointments to medical school faculties and indication as to whether a licensee has a responsibility for graduate medical education within the most recent ten (10) years; (optional), Information regarding publications in peer-reviewed medical literature; (optional) and, Information regarding professional or community service associations, activities and awards; (optional). Board of Nursing. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. endstream endobj startxref The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. 1:00 p.m. Call to Order Board Meeting Map & Directions [+]. Without your 214 2nd Avenue N. Find Your Nurse Practice Act. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. 2023 Institute for Safe Medication Practices. Contact us with any comments or questions. Board revokes the nurses professional license and fines her $3,000. To SEARCH and find an individual, press Control and 'f' keys, and type in name. 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. .`jh L@ b 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. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. 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 court for Tennessee professional licensing is the Administrative Procedures Division. 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. TN These laws are defined in the Nursing Practice Act (NPA). (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). 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. 214 2nd Avenue N., Complaints - Tennessee Please include your name, title/position, organization name, office phone and email in your request. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. 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. 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 $60,000 in prosecution costs. Virginia Board of Nursing - Disciplinary Proceedings %%EOF Getting to Know Your Licensing Board: the North Carolina Board of Nursing at a Glance; What Nurses need to know about Informatics, Social Media, and Security! For Institutions. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Together the NPA and rules/regulations guide and govern nursing practice. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). Also, the nurse was used to scanning the barcode on drug labels for verification and tried to locate a scanner to do so while in radiology, but to no availbarcode scanning technology was not available in radiology. Read our recipe for investigating nursing boards' oversight . This timeline will help. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. Contact Info Montana State Board. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. A description of any final board disciplinary actions within the most recent ten (10) years, which actions shall include final board action as defined by 4-5-314, and reprimand action taken pursuant to a board practice act; A description of any final disciplinary actions of licensing boards in other states within the most recent ten (10) years; ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Listings are sorted by the year of original Board action issued then by last name, first name. The information on this website is for general information purposes only. 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. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . Disciplinary Actions Log | North Carolina Board of Nursing RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. % PDF Disciplinary Action Report Page 1 of 18 - Tennessee 3 0 obj 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. a number of sources. Contact the board at (615) 532-5166. At the time of the error, the EHR, ADC software, and pharmacy computer system were not communicating properly, leading to significant pharmacy order verification delays. More warnings would not have changed her performance.. 437 0 obj <> endobj 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. endobj C. omplaints to nursing boards can come from . 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. The Administrative Procedures Division is the administrative court for the State. Receive the monthly Disciplinary Action Report by e-mail. %PDF-1.7 Name of Board: Tennessee Board of Nursing . _X_\~?Map0j).,XxzZ(uJ@ X{ R@-npXC +G1#!$>Wwo^-!,${W'/7$ A@B`\mu)B8@afs@6Aad&@r6[K0(+hTR]rJL|yC .=okDYp B',zR5dbdG~8hy.3a6zt #x^h%~L7 fUFA@eRiM9X:0&z-j>@95_N6lxPoYK{T#9nHZ"ip]>3>U]S Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. @3Mh?d+Nu*%5l(U9{rRA>@l=ph <> TDH Newsroom. 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. (2) In order to be issued a certificate of fitness as a nurse practitioner with . 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). 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. Below is a list of actions taken in March 2021. Speak with an attorney as soon as possible. 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. 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. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. hb```\^ !0!U[j|}+Iv0H/\K But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. . Please include your name, title/position, organization name, office phone and . PDF Rules of The Tennessee Board of Nursing Chapter 1000-04 Advanced Read our recipe for investigating nursing boards' oversight . Suite 400, 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. 1 0 obj 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. 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. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. endobj 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. 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. 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. 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. Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. 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. Complaints. See what boards of nursing are currently participating. 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. Information for health professionals regarding the COVID-19 response. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. All rights reserved. 4 0 obj 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. 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). And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. 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. 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. Please click the link below to access the licensure renewal page. We believe this is what happened here. You must have JavaScript enabled to use this form. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) Nothing on this site should be taken as legal advice for any individual 2 0 obj Receive the monthly Disciplinary Action Report bye-mail.