214 2nd Avenue N., 5200 Butler Pike Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. 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). The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. 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. 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. 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. 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. 3 0 obj Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. Nurses criminal trial is scheduled to begin. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. 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. 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? 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; 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. 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. However, was the Boards action fair and just in this situation? 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" A nurse can be disciplined for "unprofessional conduct, and negligence, Disciplinary action against her license was then filed. 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. Registered Nurse Licensed Practical Nurse Clinical Nursing Specialist Nurse Practitioner Contact: Sylvia Tamayo-Suijk, (804) 367-4502 , sylvia.tamayo-suijk@dhp.virginia.gov For: Nurse Aide Medication Aide Licensed Massage Therapist Contact: Cathy Hanchey, ( 804)367-4481 , cathy.hanchey@dhp.virginia.gov Virginia Board of Nursing She said through tears at the hearing, I wont ever be the same person. The mission of each board is to safeguard the health, safety and welfare of . Contact Info Montana State Board. But mistakes were made. Filing Complaints and Researching Disciplinary Actions . Nothing on this site should be taken as legal advice for any individual Please include your name, title/position, organization name, office phone and email in your request. Together the NPA and rules/regulations guide and govern nursing practice. <>/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>> Detailed information about disciplinary . 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. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. 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. Any change to information is required to be reported within 30 days of the change. Select Begin Here For Sign-up under New User to create your account. National Council of State Boards of Nursing, Inc. All Rights Reserved. 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. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. @3Mh?d+Nu*%5l(U9{rRA>@l=ph If you are threatened with the loss of your professional license, you must take prompt action. endobj Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. The standards are very broad. Patient involved in medication error is withdrawn from life support and dies. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. endstream endobj startxref In a Just Culture, inadvertent behavior (human error) is not worthy of disciplinary sanction, regardless of the outcome, and the quality of behavioral choices made during an event are thoroughly examined to determine whether there was conscious disregard of significant risks. 1:00 p.m. Call to Order Board Meeting Contact Info Georgia State Board. 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. Nurse retrieved a nonurgent medication from the ADC via override. 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. 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. More warnings would not have changed her performance.. 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. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. Without your 214 2nd Avenue N. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. The Administrative Procedures Division is the administrative court for the State. Monday, May 1, 2023 . The state's duty to protect those who receive nursing care is the basis for a nursing license. 0 This information is not intended to create, and receipt Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Fifty states, District of Columbia and 4 United States (US) territories . 7oM~/dc`xb7T206 )5F{w0Q ( July 23, 2021. Table 2. Contact us with any comments or questions. Click here to go to the live stream site. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. 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. %PDF-1.7 For Institutions. 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. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. TN This page has information and updates on nursing boards and regulation specific to Montana. %%EOF `g"H>O|oD)svT>VZ9,VP{PVy9[K. 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. Below is a list of actions taken in NOVEMBER 2021. 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. nunsirg ce nli es. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. Nashville Tennessean. 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. Read our recipe for investigating nursing boards' oversight . National Council of State Boards of Nursing, Inc. All Rights Reserved. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. 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. Disciplinary action against her license was then filed. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. Information for health professionals regarding the COVID-19 response. 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. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. hbbd``b`:$gP " `v nb-W&FV^ 'F <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> 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. While searching for information on a particular health care professional, consumers should be aware that there are several locations available to aid them with their research. 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. 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. Comprehensive information on protecting one's . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. or viewing does not constitute, an attorney-client relationship. Nurse did not verify that the proper medication was administered to the patient. Tennessee Department of Health Publications. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Board of Nursing Complaint Process: Investigation to Resolution. Nashville, 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. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. As a primary source equivalent the data is provided directly from the boards of nursing. 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\-; Read our recipe for investigating nursing boards' oversight . 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. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Adapted from: Kelman B. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. 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. 63-7-115. Every state and territory in the US set laws to govern the practice of nursing. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. 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. 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. Failure to consider the significant contribution of system failures. 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. Disputed failure. . Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. Name of Board: Tennessee Board of Nursing . 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! See Table 1 for a more detailed timeline of events. Board revokes the nurses professional license and fines her $3,000. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. The court for Tennessee professional licensing is the Administrative Procedures Division. 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. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. e-Notify Get free license expiration and status updates via email (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . This timeline will help. 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. 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. 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. Nurse charged with criminal reckless homicide and impaired adult abuse. 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 According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. C. omplaints to nursing boards can come from . Suite 400 Disciplinary Action Report Page 1 of 11 . 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. 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. Please secure your User ID and Password for future use. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. 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. Didn't find what you are looking for? Nurse failed to document vecuronium administration to the patient in the EHR. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. a number of sources. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. Board actions may include: Fine or civil penalty. 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 Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. 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. You must have JavaScript enabled to use this form. Available for institutions 2 0 obj <> 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. Receive the monthly Disciplinary Action Report by e-mail. 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). Drug prescription errors, while serious events are not necessarily intentional. case or situation. The information on this website is for general information purposes only. 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. 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. Nurses disciplinary licensing hearing is held. This timeline will help, Medication Safety Officers Society (MSOS). We believe this is what happened here. 466 0 obj <>stream The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". 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. These laws are defined in the Nursing Practice Act (NPA). {dhF`g)Ut9`6XX:WaVUR!@Z! Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. If you applied for initial license online, you can use the same account to renew your license. .`jh L@ b Suite 400, Board of Nursing. 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. Complaints. Time: 1:00 p.m. C.T. %PDF-1.6 % 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).
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