1432 0 obj <>stream There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. Nurse charged with criminal reckless homicide and impaired adult abuse. Unreasonable expectations. 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" Montana: Nursing Board Tracker - ProPublica When an individual is engaged in at-risk behavior, their internal risk monitor is silent. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. Currently, the annual rate of discipline on a nursing license is less than one percent. She said through tears at the hearing, I wont ever be the same person. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. 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. Disputed failure. 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. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. endobj Listings are sorted by the year of original Board action issued then by last name, first name. 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. 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 Administrative Procedures Division is the administrative court for the State. Make a User ID that you can remember, such as your email address. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) Tennessee Department of Health Publications. This page has information and updates on nursing boards and regulation specific to Georgia. %PDF-1.7 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. PDF DISCIPLINARY ACTION REPORT - Tennessee Board Action | NCSBN If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. endstream endobj startxref 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. stream 7oM~/dc`xb7T206 )5F{w0Q ( The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. 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. 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. 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 nurses license verification is available immediately to the endorsing board of nursing. endstream endobj 1407 0 obj <. 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, Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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; Nurses alleged failures and unanswered questions about the event. 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. "9$3. What Discipline Can a Board of Nursing Impose Against a Nurse Licensee 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. The court for Tennessee professional licensing is the Administrative Procedures Division. 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. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Nurses disciplinary licensing hearing is held. While the Board accepted the state prosecutors recommendation to revoke RaDondas nursing license, ISMP doubts that the Boards action was just, and we believe it set us back 25 years in patient safety. The system provides licensure and publicly available discipline data directly to you as the information is entered into the Nursys database by participating boards of nursing. Detailed information about disciplinary actions is available on . Monday, May 1, 2023 . Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. _X_\~?Map0j).,XxzZ(uJ@ X{ R@-npXC +G1#!$>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 Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. Board of Nursing Complaint Process: Investigation to Resolution. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. 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. 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. Nurse failed to document vecuronium administration to the patient in the EHR. 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. Yet, the primary way to determine the differences between at-risk and reckless behavior is to carefully consider the system-based causes that might have contributed to the behavioral choices. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. Hospital fires nurse for not following the five rights of medication administration. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. <>/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>> Adapted from: Kelman B. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Nothing on this site should be taken as legal advice for any individual 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. Survey of Advanced Practice Registered Nurses Disciplinary Action See Table 1 for a more detailed timeline of events. Board of Nursing. This information is not intended to create, and receipt Complaints - Tennessee <> This page has information and updates on nursing boards and regulation specific to Montana. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Disciplinary Actions Taken by the Board - Oregon 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. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. For Institutions. Every state and territory in the US set laws to govern the practice of nursing. 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. Lack of a thorough investigation. 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? Information Required to be Reported on Practitioner Profiles. 0 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. More warnings would not have changed her performance.. 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 . 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. Please click the link below to access the licensure renewal page. 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. We believe this is what happened here. Take disciplinary actions as necessary to protect the public from unsafe nurses. Disciplinary action against her license was then filed. <> 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. 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. Receive the monthly Disciplinary Action Report by e-mail. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. If you are threatened with the loss of your professional license, you must take prompt action. Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. 437 0 obj <> endobj Date of Meeting: May 1, 2023 . The state's duty to protect those who receive nursing care is the basis for a nursing license. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Disciplinary Actions - New Mexico Board of Nursing Disciplinary Actions by the Tennessee Board of Nursing, License revoked: LPN = 2, CNA = 5, RN = 11, License suspended: LPN = 1, CNA = 0, RN = 14, License probation: LPN = 0, CNA = 0, RN = 15, License reprimanded: LPN = 0, CNA = 0, RN = 3, 23 Drug abuse, including over-prescribing or illegal prescriptions, 02 Patient chart falsification or patient chart data recorded illegibly, 02 Drug addiction, including substance addictionor substance use on duty, 19 Incompetence, negligence or unprofessional conduct. Tennessee: Nursing Board Tracker - projects.propublica.org Place: Electronic Meeting / Poplar Room . Were they monitored and by whom and for how long? Nurse administers IV vecuronium instead of Versed (midazolam). 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. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. 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. If you applied for initial license online, you can use the same account to renew your license. 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. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. For example, one Board member suggested that a reasonable nurse would have transported the patient out of the radiology unit to a patient care unit that used barcode technology so she could scan the barcode on the medication prior to administration. Name of Board: Tennessee Board of Nursing . 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. 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. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 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. Plymouth Meeting, PA 19462. Find Your Nurse Practice Act | NCSBN TN Reporting Obligations - Minnesota Board of Nursing 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. 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. 466 0 obj <>stream It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. The mission of each board is to safeguard the health, safety and welfare of . 4 0 obj Please include your name, title/position, organization name, office phone and email in your request. 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. The information on this website is for general information purposes only. A nurse can be disciplined for "unprofessional conduct, and negligence, endobj The court for Tennessee professional licensing is the Administrative Procedures Division. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> 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 Info Montana State Board. Any change to information is required to be reported within 30 days of the change. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. This timeline will help, Medication Safety Officers Society (MSOS). endstream endobj startxref Available for institutions National Council of State Boards of Nursing, Inc. All Rights Reserved. Practitioner Profiles - Tennessee Filing Complaints and Researching Disciplinary Actions . %%EOF Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. July 13, 2020 Vaught's criminal trial is scheduled to begin. TN Board of Nursing's Unjust Decision to Revoke Nurse's License Contact Info Georgia State Board. 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. However, this failure is substantively unimportant relative to the wrong drug error. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. Nurse did not verify that the proper medication was removed from the ADC. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Institute for Safe MedicationPractices Board revokes the nurses professional license and fines her $3,000. July 23, 2021. Look up, verify and monitor your nurse licenses anytime, anywhere. PDF Disciplinary Action Report Page 1 of 18 - Tennessee DISCIPLINARY ACTION REPORT . Without your 214 2nd Avenue N. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. 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. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. As a primary source equivalent the data is provided directly from the boards of nursing. NASHVILLE, Tenn. Tennessee Code Annotated, Section 68-- 1-114 requires the Tennessee - Department of Health to issue a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. 1 0 obj Nashville Tennessean. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. C. omplaints to nursing boards can come from . While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. 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. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. 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 Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. When a BON disciplinary process is based on substance use disorder Nurse retrieved a nonurgent medication from the ADC via override. @3Mh?d+Nu*%5l(U9{rRA>@l=ph 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. 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. 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. ); 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). 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. Serious Disciplinary Actions States. 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.
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