Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . 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 whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Table 2. Filing Complaints and Researching Disciplinary Actions . Failure to recognize self-blame in second victims. During the hearing, RaDonda appeared to fall on the sword of guilt, remorse, self-doubt, loss of confidence, and a wish to make amends. nunsirg ce nli es. Date of Meeting: May 1, 2023 . 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. Below is a list of actions taken in July 2020. 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. @3Mh?d+Nu*%5l(U9{rRA>@l=ph 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. 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. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. Listed below are the meetings held for the past year. PDF DISCIPLINARY ACTION REPORT - Tennessee The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. 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. Inability to differentiate between human error, at-risk behavior, and reckless behavior. Undisputed failure but most likely at-risk, not reckless, behavior. Disciplinary action against her license was then filed. DISCIPLINARY ACTION REPORT . Filing Complaints and Researching Disciplinary Actions. 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. Georgia: Nursing Board Tracker - ProPublica 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. _X_\~?Map0j).,XxzZ(uJ@ X{ R@-npXC +G1#!$>Wwo^-!,${W'/7$ A@B`\mu)B8@afs@6Aad&@r6[K0(+hTR]rJL|yC .=okDYp B',zR5dbdG~8hy.3a6zt #x^h%~L7 fUFA@eRiM9X:0&z-j>@95_N6lxPoYK{T#9nHZ"ip]>3>U]S 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. Nurse failed to document vecuronium administration to the patient in the EHR. Look up, verify and monitor your nurse licenses anytime, anywhere. Below is a list of actions taken in NOVEMBER 2021. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. PDF Rules of The Tennessee Board of Nursing Chapter 1000-04 Advanced Detailed information about disciplinary actions is available on . (2) In order to be issued a certificate of fitness as a nurse practitioner with . 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. 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. Disciplinary Actions by the Tennessee Board of Nursing, License revoked: LPN = 2, CNA = 5, RN = 11, License suspended: LPN = 1, CNA = 0, RN = 14, License probation: LPN = 0, CNA = 0, RN = 15, License reprimanded: LPN = 0, CNA = 0, RN = 3, 23 Drug abuse, including over-prescribing or illegal prescriptions, 02 Patient chart falsification or patient chart data recorded illegibly, 02 Drug addiction, including substance addictionor substance use on duty, 19 Incompetence, negligence or unprofessional conduct. 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. This timeline will help, Medication Safety Officers Society (MSOS). Find Your Nurse Practice Act | NCSBN Request monthly Disciplinary Action Report by e-mail. 1432 0 obj <>stream 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. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". The nurses license verification is available immediately to the endorsing board of nursing. 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. 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. Nursing Practice Act - StatPearls - NCBI Bookshelf Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Discipline Meeting . When an individual is engaged in at-risk behavior, their internal risk monitor is silent. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. 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. Nursing Disciplinary Action Explained | NurseJournal.org Any change to information is required to be reported within 30 days of the change. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. See Table 1 for a more detailed timeline of events. In response to the whistleblower, CMS conducts a surprise hospital inspection. 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 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. PDF Professional Licensure: Investigation and Disciplinary Action She said through tears at the hearing, I wont ever be the same person. 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. C. omplaints to nursing boards can come from . 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. 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. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! When a BON disciplinary process is based on substance use disorder 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. Hospital fires nurse for not following the five rights of medication administration. This information is not intended to create, and receipt These laws are defined in the Nursing Practice Act (NPA). Detailed information about disciplinary . The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. 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? <> And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Read our recipe for investigating nursing boards' oversight . Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. 437 0 obj <> endobj hb```\^ !0!U[j|}+Iv0H/\K Health Professional Boards - Tennessee The Board has continued to promote a transparent disciplinary process. The professions required to submit and maintain a practitioner profile questionnaire are: Tennessee Code Annotated Title 63 Chapter 51 requires the following information to be reported to the Board for dissemination to the public on practitioner profiles: http://apps.health.tn.gov/Licensure/Default.aspx, Tennessee Department of Health Publications, Licensed Registered Respiratory Therapists, Licensed Certified Respiratory Therapists. Comprehensive information on protecting one's . News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . 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. Disciplinary Action Report Page 1 of 11 . The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Fifty states, District of Columbia and 4 United States (US) territories . Tennessee: Nursing Board Tracker - projects.propublica.org Nashville, TN 37201. Nurse did not verify that the proper medication was administered to the patient. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 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. 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. 63-7-115. This page has information and updates on nursing boards and regulation specific to Georgia. Nurse claims that after failing to find the order in the patients profile in the ADC, she called the charge nurse to make sure the order had been placed, and then entered an empty room and checked the patients electronic health record (EHR) to verify the physicians order before returning to the ADC to withdraw the drug via override. The state's duty to protect those who receive nursing care is the basis for a nursing license. Practitioner Profiles - Tennessee Contact us with any comments or questions. How to report patients abusing TennCare benefits. Time: 1:00 p.m. C.T. 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. Speak with an attorney as soon as possible. 4 0 obj Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber 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.