More warnings would not have changed her performance.. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. To SEARCH and find an individual, press Control and 'f' keys, and type in name. A nurse can be disciplined for "unprofessional conduct, and negligence, 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. Nurse retrieved a nonurgent medication from the ADC via override. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. See what boards of nursing are currently participating. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. 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. Institute for Safe MedicationPractices 1 0 obj July 23, 2021. Time: 1:00 p.m. C.T. Select Begin Here For Sign-up under New User to create your account. 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. Inability to differentiate between human error, at-risk behavior, and reckless behavior. 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. 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. 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 . Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. Every state and territory in the US set laws to govern the practice of nursing. This timeline will help, Medication Safety Officers Society (MSOS). Hospital fires nurse for not following the five rights of medication administration. 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. or viewing does not constitute, an attorney-client relationship. The Administrative Procedures Division is the administrative court for the State. 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. The state's duty to protect those who receive nursing care is the basis for a nursing license. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. `g"H>O|oD)svT>VZ9,VP{PVy9[K. Disputed failure. 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. e-Notify Get free license expiration and status updates via email Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. 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? 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. Nurses criminal trial is scheduled to begin. ); 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). U.S. a number of sources. 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. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. 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. If you are threatened with the loss of your professional license, you must take prompt action. 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. As RaDondas defense attorney said during the hearing, Rather than revoking this good nurses license, there needs to be another way. If we dont find it, we risk jeopardizing the opportunity to recruit talented people into the healthcare fieldthey wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. 1419 0 obj <>/Filter/FlateDecode/ID[<7C1E6885F79A2840B3CD3D4380937611><607411345D04C24E89F3B328005C117C>]/Index[1406 27]/Info 1405 0 R/Length 73/Prev 82019/Root 1407 0 R/Size 1433/Type/XRef/W[1 2 1]>>stream To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Disciplinary Action. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Complaints. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Detailed information about disciplinary actions is available on . ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! 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. Board members, with few exceptions, are appointed by the Governor. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. endstream endobj startxref Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Drug prescription errors, while serious events are not necessarily intentional. Speak with an attorney as soon as possible. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. Place: Electronic Meeting / Poplar Room . 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. Discipline was defined as a formal action taken by a board of nursing or a court, whereby an APRN received a formal letter of reprimand, a restriction placed on an active license or certification, such as a prohibition against narcotic access, restriction from participating in the multi-state licensure compact, suspension with or without a stay, The number of license violations per category for November 2018 are listed below: Nursing professionals in Tennessee who are threatened with the loss of their licenses can take action to protect their licenses. 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. DISCIPLINARY ACTION REPORT . Professional nursing license action report. These laws are defined in the Nursing Practice Act (NPA). . 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. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) Serious Disciplinary Actions States. The board of nursing (BON), through its statutory authority specified in the nurse practice act, is responsible for reviewing and acting on complaints in order to fulfill their mission to protect the public. 7oM~/dc`xb7T206 )5F{w0Q ( Information for health professionals regarding the COVID-19 response. 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. 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. Map & Directions [+]. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Detailed information about disciplinary . Nashville, Take disciplinary actions as necessary to protect the public from unsafe nurses. Make a User ID that you can remember, such as your email address. 37201 Accountability for not following the five rights. 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 an individual is engaged in at-risk behavior, their internal risk monitor is silent. The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. 2 0 obj Plymouth Meeting, PA 19462. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. 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). Undisputed failure but most likely at-risk, not reckless, behavior. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. TN It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. 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. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. 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 Board has continued to promote a transparent disciplinary process. endobj 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. Listings are sorted by the year of original Board action issued then by last name, first name. %PDF-1.7 The RaDonda Vaught case is confusing. 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. This page has information and updates on nursing boards and regulation specific to Georgia. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. All rights reserved. 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. Table 2. %%EOF endobj Disputed failure. Information Required to be Reported on Practitioner Profiles. 1406 0 obj <> endobj Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. 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. RaDonda's criminal trial is scheduled to begin on . 437 0 obj <> endobj Date of Meeting: May 1, 2023 . The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". 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. 1:00 p.m. Call to Order Board Meeting You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . The nurses license verification is available immediately to the endorsing board of nursing. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. However, this failure is substantively unimportant relative to the wrong drug error. Nurse did not verify that the proper medication was administered to the patient. How to report patients abusing TennCare benefits. Together the NPA and rules/regulations guide and govern nursing practice. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. 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. hb```\^ !0!U[j|}+Iv0H/\K Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. 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. 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). 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. Registered Nurse Licensed Practical Nurse Clinical Nursing Specialist Nurse Practitioner Contact: Sylvia Tamayo-Suijk, (804) 367-4502 , [email protected] For: Nurse Aide Medication Aide Licensed Massage Therapist Contact: Cathy Hanchey, ( 804)367-4481 , [email protected] Virginia Board of Nursing 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. Hospital settles with patients family, requiring them to not speak about the error publicly. Disciplinary action against her license was then filed. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. Nursys is the only national nurse licensure and disciplinary database. 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. 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. Disciplinary Action Report Page 1 of 11 . Nashville, TN 37201. Receive the monthly Disciplinary Action Report by e-mail. 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. 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. 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. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Below is a list of actions taken in NOVEMBER 2021. Contact Info Georgia State Board. endstream endobj startxref <>/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>> Look up, verify and monitor your nurse licenses anytime, anywhere. hbbd``b`:$gP " `v nb-W&FV^ 'F 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. Receive the monthly Disciplinary Action Report bye-mail. Below is a list of actions taken in July 2020. Request monthly Disciplinary Action Report by e-mail. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. (2) In order to be issued a certificate of fitness as a nurse practitioner with . 3 0 obj 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. Fifty states, District of Columbia and 4 United States (US) territories . Contact us with any comments or questions. 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. However, was the Boards action fair and just in this situation? Nurses alleged failures and unanswered questions about the event. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 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. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.).