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). . `g"H>O|oD)svT>VZ9,VP{PVy9[K. 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 process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. The RaDonda Vaught case is confusing. <>/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>> e-Notify Get free license expiration and status updates via email Board revokes the nurses professional license and fines her $3,000. hb```\^ !0!U[j|}+Iv0H/\K The court for Tennessee professional licensing is the Administrative Procedures Division. The mission of each board is to safeguard the health, safety and welfare of . 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. C. omplaints to nursing boards can come from . 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 include your name, title/position, organization name, office phone and . Disputed failure. Receive the monthly Disciplinary Action Report by e-mail. Undisputed failure but most likely at-risk, not reckless, behavior. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Undisputed failure but most likely at-risk, not reckless, behavior. The information on this website is for general information purposes only. U.S. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . The Board has continued to promote a transparent disciplinary process. Information Required to be Reported on Practitioner Profiles. Inability to differentiate between human error, at-risk behavior, and reckless behavior. 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. Nurses criminal trial is scheduled but delayed due to the pandemic. Contact the board at (615) 532-5166. Nurse administers IV vecuronium instead of Versed (midazolam). The nurses license verification is available immediately to the endorsing board of nursing. nunsirg ce nli es. 0 Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. We believe this is what happened here. As a primary source equivalent the data is provided directly from the boards of nursing. Information for health professionals regarding the COVID-19 response. Were they monitored and by whom and for how long? Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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" Board of Nursing. Contact us with any comments or questions. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. 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. "9$3. Currently, the annual rate of discipline on a nursing license is less than one percent. July 13, 2020 Vaught's criminal trial is scheduled to begin. Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign, and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm. This information is not intended to create, and receipt The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing. 3 0 obj On September 27, 2019, in a stark reversal of a 2018 decision to take no licensing action against the nurse, the TN Board of Nursing filed disciplinary action against RaDonda that focused on three violations: Unprofessional conduct related to nursing practice and the five rights of medication administration, Abandoning or neglecting a patient requiring nursing care, Failure to maintain a record of interventions. Furthermore, the Board did not determine whether RaDonda saw the risk associated with her behavior as substantial and disregarded it, and whether her internal risk monitor firedthat little voice that creeps into our conscious thoughts and lets us know we are in danger. While the vast majority of nurses are competent and caring individuals who provide care according to the standard, violations of the nurse practice act do happen. July 23, 2021. Disciplinary action against her license was then filed. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. 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. 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). Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. 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. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 1432 0 obj <>stream 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. 7oM~/dc`xb7T206 )5F{w0Q ( Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. Suite 400, Tennessee Department of Health Publications. The state's duty to protect those who receive nursing care is the basis for a nursing license. These laws are defined in the Nursing Practice Act (NPA). Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. 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. 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. Map & Directions [+]. Please include your name, title/position, organization name, office phone and email in your request. endstream endobj startxref Nurse did not verify that the proper medication was administered to the patient. DISCIPLINARY ACTION REPORT . 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 . Make a User ID that you can remember, such as your email address. Information concerning paid medical malpractice claims shall be put in context by comparing an individual licensee's medical malpractice judgment awards and settlements to the experience of other providers within the same specialty. 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. 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. 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. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. Below is a list of actions taken in NOVEMBER 2021. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . Every state and territory in the US set laws to govern the practice of nursing. Contact Info Georgia State Board. <> 63-7-115. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. Listed below are the meetings held for the past year. This timeline will help. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. 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. The standards are very broad. How to report patients abusing TennCare benefits. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. 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. Detailed information about disciplinary actions is available on . 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. If you are threatened with the loss of your professional license, you must take prompt action. 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 Disciplinary Action Report Page 1 of 11 . And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. and nurses. 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. Nurse charged with criminal reckless homicide and impaired adult abuse. Take disciplinary actions as necessary to protect the public from unsafe nurses. 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. See what boards of nursing are currently participating. .`jh L@ b 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. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. Disputed failure. Please click the link below to access the licensure renewal page. Nurses disciplinary licensing hearing is held. 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. 2023 Institute for Safe Medication Practices. 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. 1:00 p.m. Call to Order Board Meeting Place: Electronic Meeting / Poplar Room . ); 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). 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. RaDonda's criminal trial is scheduled to begin on . 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. To SEARCH and find an individual, press Control and 'f' keys, and type in name. Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . Undisputed failure. 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. Receive the monthly Disciplinary Action Report bye-mail. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Disputed failure. Projectionsbased on a single month, while not statistically accurate, suggest a large number of annual nursing license disciplinary actions may result from controlled substance issues. Nothing on this site should be taken as legal advice for any individual %%EOF <> 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. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. 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. 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, Please secure your User ID and Password for future use. 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. Filing Complaints and Researching Disciplinary Actions . 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. 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. Disciplinary action against her license was then filed. {dhF`g)Ut9`6XX:WaVUR!@Z! Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Below is a list of actions taken in March 2021. 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. Complaints. Detailed information about disciplinary . Select Begin Here For Sign-up under New User to create your account. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Nurses alleged failures and unanswered questions about the event. This timeline will help, Medication Safety Officers Society (MSOS). The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. Nurse failed to document vecuronium administration to the patient in the EHR. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv Plymouth Meeting, PA 19462. Nurse retrieved a nonurgent medication from the ADC via override. Read our recipe for investigating nursing boards' oversight . Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Disciplinary Action. 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. 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. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. 0 Together the NPA and rules/regulations guide and govern nursing practice. 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. 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 Available for institutions 1406 0 obj <> endobj 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. Listings are sorted by the year of original Board action issued then by last name, first name. Adapted from: Kelman B. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. 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. See Table 1 for a more detailed timeline of events. 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.

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