The Board has continued to promote a transparent disciplinary process. 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. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. 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. 1406 0 obj <> endobj WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. Receive the monthly Disciplinary Action Report bye-mail. @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. `g"H>O|oD)svT>VZ9,VP{PVy9[K. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. endstream endobj startxref After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Board members, with few exceptions, are appointed by the Governor. (2) In order to be issued a certificate of fitness as a nurse practitioner with . More warnings would not have changed her performance.. 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 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. DISCIPLINARY ACTION REPORT . As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. 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. Board actions may include: Fine or civil penalty. 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. Comprehensive information on protecting one's . <>/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>> TN 63-7-115. Hospital settles with patients family, requiring them to not speak about the error publicly. Without your 214 2nd Avenue N. 437 0 obj <> endobj However, RaDonda also testified that the error was made because of flawed procedures at the hospital, particularly the lack of timely communication between the pharmacy computer system and the ADC, which led to significant delays in accessing medications and the hospitals permission to temporarily override the ADC to obtain prescribed medications that were not yet linked to the patients profile in the ADC. Read our recipe for investigating nursing boards' oversight . 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\-; National Council of State Boards of Nursing, Inc. All Rights Reserved. PDF Rules of The Tennessee Board of Nursing Chapter 1000-04 Advanced Take disciplinary actions as necessary to protect the public from unsafe nurses. 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. Georgia: Nursing Board Tracker - ProPublica 0 According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Available for institutions endstream endobj 1407 0 obj <. 466 0 obj <>stream Inability to differentiate between human error, at-risk behavior, and reckless behavior. Every state and territory in the US set laws to govern the practice of nursing. Disputed failure. 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. 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. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. endobj Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. See what boards of nursing are currently participating. 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. We believe this is what happened here. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. If you are threatened with the loss of your professional license, you must take prompt action. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. 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. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. endobj Patient involved in medication error is withdrawn from life support and dies. Accountability for not following the five rights. Request monthly Disciplinary Action Report by e-mail. 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 Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . 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. 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. This information is not intended to create, and receipt case or situation. 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. Below is a list of actions taken in NOVEMBER 2021. 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. 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. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! See Table 1 for a more detailed timeline of events. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. %PDF-1.6 % or viewing does not constitute, an attorney-client relationship. 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 Information for health professionals regarding the COVID-19 response. Please include your name, title/position, organization name, office phone and . 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. % . Nurse could not carry out the physicians order to repeat the first dose if insufficient because she did not monitor the effectiveness of the first dose. 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. Montana: Nursing Board Tracker - ProPublica You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 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). 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. 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. Time: 1:00 p.m. C.T. Disciplinary Actions - New Mexico Board of Nursing 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. You must have JavaScript enabled to use this form. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. Any change to information is required to be reported within 30 days of the change. Detailed information about disciplinary . Nurse administers IV vecuronium instead of Versed (midazolam). 2023 Institute for Safe Medication Practices. 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. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. Look up, verify and monitor your nurse licenses anytime, anywhere. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Currently, the annual rate of discipline on a nursing license is less than one percent. 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). However, this failure is substantively unimportant relative to the wrong drug error. Nurse did not verify that the proper medication was administered to the patient. .`jh L@ b Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. 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. U.S. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. PDF Disciplinary Action Report Page 1 of 14 - Tennessee 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. . How to report patients abusing TennCare benefits. 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. Practitioner Profiles - Tennessee Please click the link below to access the licensure renewal page. Below is a list of actions taken in March 2021. 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. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . The standards are very broad. When a BON disciplinary process is based on substance use disorder 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. 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. Listed below are the meetings held for the past year. endstream endobj startxref _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 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. Place: Electronic Meeting / Poplar Room . 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? 214 2nd Avenue N., Disputed failure. Monday, May 1, 2023 . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Disciplinary action against her license was then filed. The court for Tennessee professional licensing is the Administrative Procedures Division. License action type by Tennessee nursing professional. 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. In response to the whistleblower, CMS conducts a surprise hospital inspection. July 13, 2020 Vaught's criminal trial is scheduled to begin. Nurses criminal trial is scheduled to begin.