Fifty states, District of Columbia and 4 United States (US) territories . Look up, verify and monitor your nurse licenses anytime, anywhere. Detailed information about disciplinary . Nurses disciplinary licensing hearing is held. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Nurse failed to document vecuronium administration to the patient in the EHR. This information is not intended to create, and receipt Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. 63-7-115. case or situation. 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. 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, See Table 1 for a more detailed timeline of events. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Board of Nursing. National Council of State Boards of Nursing, Inc. All Rights Reserved. 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. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Make a User ID that you can remember, such as your email address. e-Notify Get free license expiration and status updates via email Plymouth Meeting, PA 19462. 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. Nurse retrieved a nonurgent medication from the ADC via override. Disciplinary Action Report Page 1 of 11 . Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. 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. Institute for Safe MedicationPractices Name of Board: Tennessee Board of Nursing . If you applied for initial license online, you can use the same account to renew your license. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. In response to the whistleblower, CMS conducts a surprise hospital inspection. 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. .`jh L@ b Suite 400, ); 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). 5200 Butler Pike 37201 Undisputed failure but most likely at-risk, not reckless, behavior. Nothing on this site should be taken as legal advice for any individual News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. Below is a list of actions taken in NOVEMBER 2021. 437 0 obj <> endobj endobj Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. National Council of State Boards of Nursing, Inc. All Rights Reserved. Every state and territory in the US set laws to govern the practice of nursing. July 13, 2020 Vaught's criminal trial is scheduled to begin. Adapted from: Kelman B. 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. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. nunsirg ce nli es. Contact us with any comments or questions. This page has information and updates on nursing boards and regulation specific to Montana. Filing Complaints and Researching Disciplinary Actions. Inability to differentiate between human error, at-risk behavior, and reckless behavior. 2 0 obj "9$3. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. RaDonda could not have consciously disregarded a substantial and unjustifiable riska requirement for reckless behaviorbecause she had no idea that she had made a mistake. NASHVILLE, Tenn. Tennessee Code Annotated, Section 68-- 1-114 requires the Tennessee - Department of Health to issue a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. 466 0 obj <>stream To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. What is NOT in dispute is that the hospital could have made barcode scanning technology a priority in radiology, given its high reliability for managing the risk of a competent, caring nurse showing up with the wrong drug in hand, as happened here. Drug prescription errors, while serious events are not necessarily intentional. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. x|83"n lNb:;U}#(jW5m?{8}q~;.>>vK}s[M^^\8_r%N){\~A9aH\9c$f#;_z5]m3g`utfpub>WdU_8WD,(Qs>qhD"63P22.3d|`zKA(%#PIA$1q?JwDU;G\-; 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 removed from the ADC. How to report patients abusing TennCare benefits. Disciplinary action against her license was then filed. The RaDonda Vaught case is confusing. Below is a list of actions taken in March 2021. Disciplinary action against her license was then filed. 4 0 obj However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. Table 2. But mistakes were made. 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. and nurses. 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. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. 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. 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 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. Serious Disciplinary Actions States. Date of Meeting: May 1, 2023 . Nurse did not verify that the proper medication was administered to the patient. <> 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. Any change to information is required to be reported within 30 days of the change. Nashville, Complaints. 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. 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. 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. 0 Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. The Board has continued to promote a transparent disciplinary process. 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. Information for health professionals regarding the COVID-19 response. 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? However, was the Boards action fair and just in this situation? Disputed failure. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. %%EOF 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. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. 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. 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. 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 . Disputed failure. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. RaDonda's criminal trial is scheduled to begin on . The state's duty to protect those who receive nursing care is the basis for a nursing license. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Click here to go to the live stream site. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Contact Info Montana State Board. 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. Nurse administers IV vecuronium instead of Versed (midazolam). or viewing does not constitute, an attorney-client relationship. 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. License action type by Tennessee nursing professional. %PDF-1.6 % 1:00 p.m. Call to Order Board Meeting If the after a thorough investigation, the BON determines there is sufficient basis that the nurse violated the act or regulations, the BON may take disciplinary action on the nurses license.
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