Suite 400 (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Nothing on this site should be taken as legal advice for any individual Contact Info Georgia State Board. 37201 Nursys The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". 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. 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. Table 2. 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. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. These laws are defined in the Nursing Practice Act (NPA). Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. To SEARCH and find an individual, press Control and 'f' keys, and type in name. Accountability for not following the five rights. 1 0 obj C. omplaints to nursing boards can come from . hb```\^ !0!U[j|}+Iv0H/\K As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. 63-7-115. PDF Rules of The Tennessee Board of Nursing Chapter 1000-04 Advanced PDF DISCIPLINARY ACTION REPORT - Tennessee Undisputed failure but most likely at-risk, not reckless, behavior. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. @3Mh?d+Nu*%5l(U9{rRA>@l=ph Health Professionals Boards Disciplinary Actions - Tennessee 1432 0 obj <>stream Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . Below is a list of actions taken in NOVEMBER 2021. 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. 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). 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. 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. 1406 0 obj <> endobj 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. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. 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. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. Disputed failure. Undisputed failure but most likely at-risk, not reckless, behavior. Professional nursing license action report. 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. 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. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Contact Info Montana State Board. Receive the monthly Disciplinary Action Report bye-mail. Currently, the annual rate of discipline on a nursing license is less than one percent. 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 Undisputed failure. .`jh L@ b Nurse did not verify that the proper medication was removed from the ADC. 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, 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. 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. 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. hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 Nurses disciplinary licensing hearing is held. 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. National Council of State Boards of Nursing, Inc. All Rights Reserved. Nurse administers IV vecuronium instead of Versed (midazolam). Plymouth Meeting, PA 19462. e-Notify Get free license expiration and status updates via email Filing Complaints and Researching Disciplinary Actions . The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. 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. 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? Disciplinary Actions Taken by the Board - Oregon Discipline Meeting . Unreasonable expectations. 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. The standards are very broad. 0 The state's duty to protect those who receive nursing care is the basis for a nursing license. Nurse did not verify that the proper medication was administered to the patient. Any change to information is required to be reported within 30 days of the change. _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 Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. This timeline will help, Medication Safety Officers Society (MSOS). Without your 214 2nd Avenue N. Nashville, TN 37201. The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws. Serious Disciplinary Actions States. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . Disputed failure. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Board members, with few exceptions, are appointed by the Governor. 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. Comprehensive information on protecting one's . The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Board of Nursing. TN Board of Nursing's Unjust Decision to Revoke Nurse's License 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). 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. case or situation. Nashville, Hospital settles with patients family, requiring them to not speak about the error publicly. 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 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. Look up, verify and monitor your nurse licenses anytime, anywhere. Discipline | NCSBN <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Disciplinary Action. Please include your name, title/position, organization name, office phone and . Receive the monthly Disciplinary Action Report by e-mail. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. All rights reserved. Survey of Advanced Practice Registered Nurses Disciplinary Action PDF Tennessee Department of Health Health Related Boards Memorandum Filing Complaints and Researching Disciplinary Actions. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. 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. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. 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. 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. Listed below are the meetings held for the past year. 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. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. 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. National Council of State Boards of Nursing, Inc. All Rights Reserved. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. 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. See Table 1 for a more detailed timeline of events. Request monthly Disciplinary Action Report by e-mail. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. 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. Nursing Disciplinary Action Explained | NurseJournal.org When a BON disciplinary process is based on substance use disorder Practitioner Profiles - Tennessee 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" Listings are sorted by the year of original Board action issued then by last name, first name. %PDF-1.7 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. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. 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. Place: Electronic Meeting / Poplar Room . You must be logged in to view and download this document. Nurses alleged failures and unanswered questions about the event. 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. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. 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. 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. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. If you are threatened with the loss of your professional license, you must take prompt action. endstream endobj 1407 0 obj <. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. Disciplinary action against her license was then filed. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. This timeline will help. 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. stream 1:00 p.m. Call to Order Board Meeting %PDF-1.5 % However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. 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. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. This information is not intended to create, and receipt The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Adapted from: Kelman B. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. July 13, 2020 Vaught's criminal trial is scheduled to begin. Together the NPA and rules/regulations guide and govern nursing practice. This page has information and updates on nursing boards and regulation specific to Georgia. Patient involved in medication error is withdrawn from life support and dies. July 23, 2021. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. However, was the Boards action fair and just in this situation? Monday, May 1, 2023 . Disputed failure. Hospital fires nurse for not following the five rights of medication administration. The RaDonda Vaught case is confusing. Undisputed failure but most likely at-risk, not reckless, behavior. Map & Directions [+]. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. 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. 437 0 obj <> endobj 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. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . 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. Read our recipe for investigating nursing boards' oversight . or viewing does not constitute, an attorney-client relationship. You must have JavaScript enabled to use this form. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Every state and territory in the US set laws to govern the practice of nursing. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. U.S. Nashville Tennessean. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . PDF Disciplinary Action Report Page 1 of 18 - Tennessee 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. Suite 400, Disciplinary Actions - New Mexico Board of Nursing The Board has continued to promote a transparent disciplinary process. Please click the link below to access the licensure renewal page. 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 Board called for the revocation of RaDondas nursing license and fines of up to $3,000. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. 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. 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. Select Begin Here For Sign-up under New User to create your account. The mission of each board is to safeguard the health, safety and welfare of . 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. Fifty states, District of Columbia and 4 United States (US) territories . 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. Find Your Nurse Practice Act. Complaints. Make a User ID that you can remember, such as your email address. 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? The nurses license verification is available immediately to the endorsing board of nursing. 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. 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. Inability to differentiate between human error, at-risk behavior, and reckless behavior. nunsirg ce nli es. Complaints - Tennessee Click here to go to the live stream site. Nurse failed to document vecuronium administration to the patient in the EHR. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv 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.
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