In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. Disciplinary action against her license was then filed. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. Contact the board at (615) 532-5166. 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 According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. 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. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. Please include your name, title/position, organization name, office phone and . 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. <>/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>> If it was a choice to not read the front of the label, at worse, it would be an at-risk behavior since most decisions are made on the fly in the subconscious, without the risk monitor firing. Below is a list of actions taken in NOVEMBER 2021. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Name of Board: Tennessee Board of Nursing . 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. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. 437 0 obj <> endobj In response to the whistleblower, CMS conducts a surprise hospital inspection. DISCIPLINARY ACTION REPORT . Nurse failed to document vecuronium administration to the patient in the EHR. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Nurses criminal trial is scheduled but delayed due to the pandemic. Select Begin Here For Sign-up under New User to create your account. Date of Meeting: May 1, 2023 . Board of Nursing. 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. Receive the monthly Disciplinary Action Report by e-mail. 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. However, this failure is substantively unimportant relative to the wrong drug error. nunsirg ce nli es. 466 0 obj <>stream Disputed failure. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. 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. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. {dhF`g)Ut9`6XX:WaVUR!@Z! Hospital fires nurse for not following the five rights of medication administration. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. ); 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). RaDonda's criminal trial is scheduled to begin on . 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. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Nursys is the only national nurse licensure and disciplinary database. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Please include your name, title/position, organization name, office phone and email in your request. If you applied for initial license online, you can use the same account to renew your license. Discipline Meeting . or viewing does not constitute, an attorney-client relationship. The nurses license verification is available immediately to the endorsing board of nursing. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. endstream endobj startxref 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. This timeline will help, Medication Safety Officers Society (MSOS). e-Notify Get free license expiration and status updates via email 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. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. Board of Nursing Complaint Process: Investigation to Resolution. 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. Listings are sorted by the year of original Board action issued then by last name, first name. 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, 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. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. Drug prescription errors, while serious events are not necessarily intentional. You must have JavaScript enabled to use this form. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. 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. Nashville, Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. Professional nursing license action report. . 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, But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. 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; 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 information on this website is for general information purposes only. Read our recipe for investigating nursing boards' oversight . Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. Currently, the annual rate of discipline on a nursing license is less than one percent. 5200 Butler Pike 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. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. 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. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. 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. endobj Board actions may include: Fine or civil penalty. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> 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. %%EOF Receive the monthly Disciplinary Action Report bye-mail. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv Didn't find what you are looking for? Unreasonable expectations. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. The mission of each board is to safeguard the health, safety and welfare of . The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. 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. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. All rights reserved. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. 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. National Council of State Boards of Nursing, Inc. All Rights Reserved. Board members, with few exceptions, are appointed by the Governor. Contact Info Georgia State Board. %PDF-1.6 % The standards are very broad. case or situation. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . % See what boards of nursing are currently participating. How to report patients abusing TennCare benefits. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. endstream endobj startxref Table 2. Nurse retrieved a nonurgent medication from the ADC via override. 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. However, was the Boards action fair and just in this situation? Accountability for not following the five rights. Nursing Licensure for Internationally Educated Nurses, See what boards of nursing are currently participating, Enhance communication between member boards, Retrieve discipline and various other reports. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. 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. Disputed failure. 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. Detailed information about disciplinary actions is available on . Undisputed failure but most likely human error, not reckless behavior. 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. She said through tears at the hearing, I wont ever be the same person. 0 Nothing on this site should be taken as legal advice for any individual WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . state by state marital signature requirements 2021,

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