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. Make a User ID that you can remember, such as your email address. 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. Nurse did not verify that the proper medication was removed from the ADC. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. hb```\^ !0!U[j|}+Iv0H/\K stream 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. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) 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. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . If you applied for initial license online, you can use the same account to renew your license. This page has information and updates on nursing boards and regulation specific to Montana. National Council of State Boards of Nursing, Inc. All Rights Reserved. This page has information and updates on nursing boards and regulation specific to Georgia. 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. . The nurses license verification is available immediately to the endorsing board of nursing. 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. % The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". and nurses. endobj Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Together the NPA and rules/regulations guide and govern nursing practice. Nursys is the only national nurse licensure and disciplinary database. endobj %PDF-1.5 % <>/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>> Please secure your User ID and Password for future use. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . 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. However, was the Boards action fair and just in this situation? Time: 1:00 p.m. C.T. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. 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. Please include your name, title/position, organization name, office phone and email in your request. a number of sources. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Were they monitored and by whom and for how long? To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Every state and territory in the US set laws to govern the practice of nursing. Without your 214 2nd Avenue N. 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. 1432 0 obj <>stream or viewing does not constitute, an attorney-client relationship. 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. Board members, with few exceptions, are appointed by the Governor. nunsirg ce nli es. 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. 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). 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). 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. To be clear, nurses cannot be held accountable for achieving the five rights; they can only be held accountable for following the processes that their organizations have designed and held out as the best way to verify the five rights. 5200 Butler Pike RaDonda's criminal trial is scheduled to begin on . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. A payment in settlement of a medical malpractice action or claim should not be construed as creating a presumption that medical malpractice has occurred. (Pending malpractice claims shall not be disclosed by a board to the public. The Office of Consumer Right to Know is charged with seeking and collecting this information and providing it to consumers via the Departments web site. 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. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. 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. 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. License action type by Tennessee nursing professional. Please include your name, title/position, organization name, office phone and . How to report patients abusing TennCare benefits. <> Filing Complaints and Researching Disciplinary Actions. Disciplinary hearings are conducted in accordance with the "Open Meetings Act" NMSA 1978, Chapter 10, Article 15 and all disciplinary actions are listed on the Board website and published in the Board newsletter quarterly. The standards are very broad. 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. 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. But mistakes were made. Look up, verify and monitor your nurse licenses anytime, anywhere. Table 2. You must be logged in to view and download this document. Adapted from: Kelman B. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. 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. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. %PDF-1.6 % 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. 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. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. See what boards of nursing are currently participating. 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. The court for Tennessee professional licensing is the Administrative Procedures Division. 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. 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. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Place: Electronic Meeting / Poplar Room . 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. See Table 1 for a more detailed timeline of events. Below is a list of actions taken in July 2020. Professional nursing license action report. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. 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" Tennessee Department of Health Publications. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. She said through tears at the hearing, I wont ever be the same person. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. 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. 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. Furthermore, the Board did not determine whether RaDonda saw the risk associated with her behavior as substantial and disregarded it, and whether her internal risk monitor firedthat little voice that creeps into our conscious thoughts and lets us know we are in danger. Nurses criminal trial is scheduled to begin. endstream endobj 1407 0 obj <. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. 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 Board has continued to promote a transparent disciplinary process. This timeline will help. Patient involved in medication error is withdrawn from life support and dies. 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. In response to the whistleblower, CMS conducts a surprise hospital inspection. Failure to consider the significant contribution of system failures. "9$3. Nurses alleged failures and unanswered questions about the event. Any actions taken by the boards must be filed with the Administrative Procedures Division of the Secretary of States Office in which effective dates will be assigned. Nurse administers IV vecuronium instead of Versed (midazolam). In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . You must have JavaScript enabled to use this form. Registered Nurse Licensed Practical Nurse Clinical Nursing Specialist Nurse Practitioner Contact: Sylvia Tamayo-Suijk, (804) 367-4502 , sylvia.tamayo-suijk@dhp.virginia.gov For: Nurse Aide Medication Aide Licensed Massage Therapist Contact: Cathy Hanchey, ( 804)367-4481 , cathy.hanchey@dhp.virginia.gov Virginia Board of Nursing hbbd``b`:$gP " `v nb-W&FV^ 'F 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. endstream endobj startxref e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. The Administrative Procedures Division is the administrative court for the State. Disciplinary Action Report Page 1 of 11 . 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, Contact us with any comments or questions. Receive the monthly Disciplinary Action Report bye-mail. 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? Read our recipe for investigating nursing boards' oversight . 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. Undisputed failure but most likely at-risk, not reckless, behavior. .`jh L@ b hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 2023 Institute for Safe Medication Practices. 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. Detailed information about disciplinary actions is available on . Disciplinary action against her license was then filed. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. 1:00 p.m. Call to Order Board Meeting Information for health professionals regarding the COVID-19 response. As a primary source equivalent the data is provided directly from the boards of nursing. 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. 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. Nurses criminal trial is scheduled but delayed due to the pandemic. Hospital settles with patients family, requiring them to not speak about the error publicly. (2) In order to be issued a certificate of fitness as a nurse practitioner with . There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Available for institutions Below is a list of actions taken in NOVEMBER 2021. 37201 Board actions may include: Fine or civil penalty. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. Nurse did not verify that the proper medication was administered to the patient. {dhF`g)Ut9`6XX:WaVUR!@Z! 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. 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. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> 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. 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. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. The RaDonda Vaught case is confusing. Any change to information is required to be reported within 30 days of the change. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. If you are threatened with the loss of your professional license, you must take prompt action. Serious Disciplinary Actions States. However, this failure is substantively unimportant relative to the wrong drug error. Disputed failure. `g"H>O|oD)svT>VZ9,VP{PVy9[K. Listed below are the meetings held for the past year. 7oM~/dc`xb7T206 )5F{w0Q ( Undisputed failure but most likely at-risk, not reckless, behavior. <> Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. 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. Nurse retrieved a nonurgent medication from the ADC via override. ISMP believes the TN Board of Nursings disciplinary processes and judgment of RaDondas actions during this event are NOT aligned with the tenets of a Just Culture. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. Undisputed failure but most likely human error, not reckless behavior. 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. 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. ); 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). 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. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. The state's duty to protect those who receive nursing care is the basis for a nursing license. Nashville, TN 37201. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. 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. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 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. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. We believe this is what happened here. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. 437 0 obj <> endobj Nashville Tennessean. To determine what a reasonable nurse would do, the Board used a null hypothesis (suggesting no differences between nurses working in different systems) with a rigid lens in a vacuum, not actual nurses who were similarly situated, often leading to unreasonable expectations of a nurse. Click here to go to the live stream site. Accountability for not following the five rights. 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. 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. Select Begin Here For Sign-up under New User to create your account. C. omplaints to nursing boards can come from . And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Currently, the annual rate of discipline on a nursing license is less than one percent. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Board revokes the nurses professional license and fines her $3,000. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). Monday, May 1, 2023 . Board of Nursing Complaint Process: Investigation to Resolution. 63-7-115. Listings are sorted by the year of original Board action issued then by last name, first name. 2 0 obj 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.

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