Fifty states, District of Columbia and 4 United States (US) territories . If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. 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 RaDonda Vaught case is confusing. Practitioner Profiles - Tennessee Disputed failure. Board of Nursing Complaint Process: Investigation to Resolution. It is not our intent to embarrass or diminish the TNBoard of Nursing by pointing out what we find disturbing or unjust in the deliberations of this complex matter, but rather to find a better way to achieve justice, learning, and improvement in safety. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Contact the board at (615) 532-5166. 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. You must have JavaScript enabled to use this form. Nursing Disciplinary Action Explained | NurseJournal.org %PDF-1.6 % 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. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. This timeline will help. Disputed failure. Reporting Obligations - Minnesota Board of Nursing 2 0 obj Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Together the NPA and rules/regulations guide and govern nursing practice. endstream endobj startxref RaDonda's criminal trial is scheduled to begin on . Professional nursing license action report. 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. Information Required to be Reported on Practitioner Profiles. %PDF-1.5 % WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. 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. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. Lack of a thorough investigation. Please click the link below to access the licensure renewal page. Filing Complaints and Researching Disciplinary Actions. . Contact Info Montana State Board. Health Professionals Boards Disciplinary Actions - Tennessee Board actions may include: Fine or civil penalty. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ National Council of State Boards of Nursing, Inc. All Rights Reserved. Any change to information is required to be reported within 30 days of the change. If you applied for initial license online, you can use the same account to renew your license. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) Adapted from: Kelman B. 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. Nurse charged with criminal reckless homicide and impaired adult abuse. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv 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. 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. PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. Suite 400 PDF Tennessee Department of Health Health Related Boards Memorandum Tennessee Department of Health Publications. This timeline will help, Medication Safety Officers Society (MSOS). Receive the monthly Disciplinary Action Report by e-mail. 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). Also, it cannot be asserted that the failure to document in the EHR contributed to the patients harm or denied her any opportunity for recovery. Nashville Tennessean. .`jh L@ b Please secure your User ID and Password for future use. <> Nursys is the only national nurse licensure and disciplinary database. Read our recipe for investigating nursing boards' oversight . (2) In order to be issued a certificate of fitness as a nurse practitioner with . and nurses. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. 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\-; RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. Disciplinary Action. License action type by Tennessee nursing professional. Serious Disciplinary Actions States. 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. 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. endstream endobj startxref Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. While the Board believed it was conscious disregard to not read the label, this is likely human error, as it happened inadvertently when she saw that the drug was a powder and quickly turned the vial over. Nurses can verify their licenses by completing the Nursys verification process for $30 per license type, per each board of nursing where the nurse is applying. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign, and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. For the purposes of this subsection (a), a person shall be deemed to be convicted of a crime if such person was found or adjudged guilty by a court of competent jurisdiction. Information concerning paid medical malpractice claims shall be put in context by comparing an individual licensee's medical malpractice judgment awards and settlements to the experience of other providers within the same specialty. Information for health professionals regarding the COVID-19 response. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. e-Notify Get free license expiration and status updates via email But the five rights are merely broadly stated goals or desired outcomes of safe medication practices that offer no procedural guidance on how to achieve these goals. If it was a choice to not read the front of the label, at worse, it would be an at-risk behavior since most decisions are made on the fly in the subconscious, without the risk monitor firing. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! However, was the Boards action fair and just in this situation? The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. The state's duty to protect those who receive nursing care is the basis for a nursing license. Nurse did not verify that the proper medication was removed from the ADC. You must be logged in to view and download this document. 7oM~/dc`xb7T206 )5F{w0Q ( 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. In response to the whistleblower, CMS conducts a surprise hospital inspection. National Council of State Boards of Nursing, Inc. All Rights Reserved. TN Board of Nursing's Unjust Decision to Revoke Nurse's License Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. 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. Plymouth Meeting, PA 19462. DISCIPLINARY ACTION REPORT . 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. To SEARCH and find an individual, press Control and 'f' keys, and type in name. 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. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 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. Request monthly Disciplinary Action Report by e-mail. 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 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. Discipline Meeting . Nurse retrieved a nonurgent medication from the ADC via override. 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. Undisputed failure. 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. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. 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. Hospital fires nurse for not following the five rights of medication administration. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Disciplinary Actions Taken by the Board - Oregon Patient involved in medication error is withdrawn from life support and dies. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Disciplinary Actions - New Mexico Board of Nursing hb```\^ !0!U[j|}+Iv0H/\K Find Your Nurse Practice Act. The Board called for the revocation of RaDondas nursing license and fines of up to $3,000.