tn board of nursing disciplinary actions
tn board of nursing disciplinary actions
Nurses disciplinary hearing is scheduled but delayed due to the pandemic. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. 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? 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. Click here to go to the live stream site. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. 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 July 23, 2021. 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. Date of Meeting: May 1, 2023 . Nurse did not verify that the proper medication was removed from the ADC. The Administrative Procedures Division is the administrative court for the State. <>/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>> 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. 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. (2) In order to be issued a certificate of fitness as a nurse practitioner with . Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) Discipline Meeting . 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. endstream endobj startxref 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. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. 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. Undisputed failure but most likely at-risk, not reckless, behavior. Nashville, {dhF`g)Ut9`6XX:WaVUR!@Z! 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 . 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. Disciplinary Action Report Page 1 of 11 . <> Contact Info Georgia State Board. Suite 400 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. This timeline will help, Medication Safety Officers Society (MSOS). More warnings would not have changed her performance.. a number of sources. Undisputed failure but most likely at-risk, not reckless, behavior. Disputed failure. Currently, the annual rate of discipline on a nursing license is less than one percent. . To cite another example, the prosecutor stated that a reasonable nurse would have seen that the ADC defaulted to searching by the generic drug name, not the brand name (which was difficult to notice at the time), rather than recognizing that the capability of the ADC to simultaneously search by brand and generic names would have been so much more effective. Getting to Know Your Licensing Board: the North Carolina Board of Nursing at a Glance; What Nurses need to know about Informatics, Social Media, and Security! Nursys is the only national nurse licensure and disciplinary database. 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). 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. Receive the monthly Disciplinary Action Report by e-mail. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. Nurse charged with criminal reckless homicide and impaired adult abuse. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). She said through tears at the hearing, I wont ever be the same person. Take disciplinary actions as necessary to protect the public from unsafe nurses. Drug prescription errors, while serious events are not necessarily intentional. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 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. Place: Electronic Meeting / Poplar Room . Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. 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. endobj 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. 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. 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. 1:00 p.m. Call to Order Board Meeting Contact the board at (615) 532-5166. Disputed failure. 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. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. 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. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. 63-7-115. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. nunsirg ce nli es. Nurses disciplinary licensing hearing is held. We believe this is what happened here. This page has information and updates on nursing boards and regulation specific to Georgia. 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. 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. 466 0 obj <>stream or viewing does not constitute, an attorney-client relationship. 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. Institute for Safe MedicationPractices 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? 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. %PDF-1.6 % Fifty states, District of Columbia and 4 United States (US) territories . 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. 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. stream Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. 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. Nurses criminal trial is scheduled but delayed due to the pandemic. The state's duty to protect those who receive nursing care is the basis for a nursing license. 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 nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. 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" 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). Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. Nurses alleged failures and unanswered questions about the event. 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. The nurses license verification is available immediately to the endorsing board of nursing. July 13, 2020 Vaught's criminal trial is scheduled to begin. endstream endobj startxref 5200 Butler Pike When an individual is engaged in at-risk behavior, their internal risk monitor is silent. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Look up, verify and monitor your nurse licenses anytime, anywhere. As a primary source equivalent the data is provided directly from the boards of nursing. Nurses criminal trial is scheduled to begin. 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. 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. Adapted from: Kelman B. Filing Complaints and Researching Disciplinary Actions . e-Notify Get free license expiration and status updates via email 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. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". 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. 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. 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. Inability to differentiate between human error, at-risk behavior, and reckless behavior. 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. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> 1432 0 obj <>stream 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. .`jh L@ b RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. Patient involved in medication error is withdrawn from life support and dies. 2 0 obj The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. 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. %PDF-1.5 % 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 Below is a list of actions taken in March 2021. Undisputed failure but most likely human error, not reckless behavior. case or situation. Were they monitored and by whom and for how long? endobj 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. RaDondas criminal trial is scheduled to begin on March 21, 2022. 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. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . But mistakes were made. 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. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. endstream endobj 1407 0 obj <. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. Please include your name, title/position, organization name, office phone and . All rights reserved. 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; To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. You must be logged in to view and download this document. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake.
