7oM~/dc`xb7T206 )5F{w0Q ( Nashville, TN 37201. 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. 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. The information on this website is for general information purposes only. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. 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. All rights reserved. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) 37201 Hospital fires nurse for not following the five rights of medication administration. 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. Unreasonable expectations. Together the NPA and rules/regulations guide and govern nursing practice. U.S. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. Below is a list of actions taken in March 2021. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. This timeline will help, Medication Safety Officers Society (MSOS). 3 0 obj However, was the Boards action fair and just in this situation? 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). 2023 Institute for Safe Medication Practices. Nurse administers IV vecuronium instead of Versed (midazolam). a number of sources. 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. Board members, with few exceptions, are appointed by the Governor. Board of Nursing. 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. Detailed information about disciplinary actions is available on . 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. You must have JavaScript enabled to use this form. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. National Council of State Boards of Nursing, Inc. All Rights Reserved. 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. Serious Disciplinary Actions States. Didn't find what you are looking for? 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. Comprehensive information on protecting one's . Tennessee Department of Health Publications. Read our recipe for investigating nursing boards' oversight . 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. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Undisputed failure but most likely at-risk, not reckless, behavior. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. 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. 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. Institute for Safe MedicationPractices 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. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. 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). Contact the board at (615) 532-5166. %PDF-1.7 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. e-Notify Get free license expiration and status updates via email Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . July 13, 2020 Vaught's criminal trial is scheduled to begin. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . 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. Receive the monthly Disciplinary Action Report by e-mail. Currently, the annual rate of discipline on a nursing license is less than one percent. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Nursys is the only national nurse licensure and disciplinary database. 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. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. 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. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Receive the monthly Disciplinary Action Report bye-mail. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. 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. stream 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 . 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\-; The mission of each board is to safeguard the health, safety and welfare of . Request monthly Disciplinary Action Report by e-mail. 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. 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. %PDF-1.6 % (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . 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. RaDondas criminal trial is scheduled to begin on March 21, 2022. % Board revokes the nurses professional license and fines her $3,000. 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). 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. 214 2nd Avenue N., The court for Tennessee professional licensing is the Administrative Procedures Division. You must be logged in to view and download this document. Discipline Meeting . Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . hb```\^ !0!U[j|}+Iv0H/\K Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. 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. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. endobj "9$3. <> Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. 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. 0 Nurses disciplinary hearing is scheduled but delayed due to the pandemic. nunsirg ce nli es. 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. 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. Nurses alleged failures and unanswered questions about the event. . Fifty states, District of Columbia and 4 United States (US) territories . 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. 2 0 obj Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. 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. Patient involved in medication error is withdrawn from life support and dies. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. 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 $60,000 in prosecution costs. case or situation. Time: 1:00 p.m. C.T. Information for health professionals regarding the COVID-19 response. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Patients, coworkers, members of the public, or employers can call the board of nursing, put complaints in writing, or complete a board of nursing Web site complaint form. Read our recipe for investigating nursing boards' oversight . hbbd``b`:$gP " `v nb-W&FV^ 'F This page has information and updates on nursing boards and regulation specific to Montana. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. 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. %PDF-1.5 % 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). Inability to differentiate between human error, at-risk behavior, and reckless behavior. C. omplaints to nursing boards can come from . Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. This information is not intended to create, and receipt 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. 4 0 obj Filing Complaints and Researching Disciplinary Actions. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Suite 400, 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 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. The Administrative Procedures Division is the administrative court for the State. 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. Nurses criminal trial is scheduled but delayed due to the pandemic. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. 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. Undisputed failure but most likely human error, not reckless behavior. Undisputed failure but most likely at-risk, not reckless, behavior. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. 5200 Butler Pike 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. Available for institutions 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 example, in the case of suspected theft or misappropriation, were there other professionals or employees present who had access to the alleged misappropriated items? The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. 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. 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. 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. DISCIPLINARY ACTION REPORT . 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. Nashville, 0 Adapted from: Kelman B. The boards interpret the laws, rules and regulations to determine the appropriate standards of practice in an effort to ensure the highest degree of professional conduct. In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. 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. Below is a list of actions taken in NOVEMBER 2021. Listed below are the meetings held for the past year. If you are threatened with the loss of your professional license, you must take prompt action. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. {dhF`g)Ut9`6XX:WaVUR!@Z! Complaints. 1406 0 obj <> endobj The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. 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? We believe this is what happened here. Drug prescription errors, while serious events are not necessarily intentional. Failure to consider the significant contribution of system failures. Nurse charged with criminal reckless homicide and impaired adult abuse. License action type by Tennessee nursing professional. 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. Suite 400 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. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. The court for Tennessee professional licensing is the Administrative Procedures Division. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . If you applied for initial license online, you can use the same account to renew your license. 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" To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. 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. 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. Click here to go to the live stream site. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. The RaDonda Vaught case is confusing. Disciplinary Action. endstream endobj startxref hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 July 23, 2021. Nurse did not verify that the proper medication was removed from the ADC. 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. Information Required to be Reported on Practitioner Profiles. 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. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing. 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. 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. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. 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. 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. 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. See what boards of nursing are currently participating. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. 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; This timeline will help. 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. 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. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. 437 0 obj <> endobj Table 2. Lack of a thorough investigation. She said through tears at the hearing, I wont ever be the same person. endstream endobj 1407 0 obj <. ); 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). 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 Filing Complaints and Researching Disciplinary Actions . 1432 0 obj <>stream ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates.

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