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 Tennessee Department of Health Health Related Boards Memorandum 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. 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. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Nurses disciplinary licensing hearing is held. 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). 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. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. Filing Complaints and Researching Disciplinary Actions. Listings are sorted by the year of original Board action issued then by last name, first name. 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. 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; The RaDonda Vaught case is confusing. 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. Below is a list of actions taken in July 2020. 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. ); 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). However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. 4 0 obj These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. 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! 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. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. This page has information and updates on nursing boards and regulation specific to Georgia. 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. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". 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. Table 2. This information is not intended to create, and receipt 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. 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. Disciplinary Actions - New Mexico 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. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . 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. Disputed failure. 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. Time: 1:00 p.m. C.T. What Discipline Can a Board of Nursing Impose Against a Nurse Licensee After discussions on this topic, the nurse did not think she had a duty to monitor the patient. Disciplinary action against her license was then filed. Read our recipe for investigating nursing boards' oversight . 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. C. omplaints to nursing boards can come from . 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 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. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. How to report patients abusing TennCare benefits. 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. Virginia Board of Nursing - Disciplinary Proceedings TDH Newsroom. 1432 0 obj <>stream But mistakes were made. 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. PDF Professional Licensure: Investigation and Disciplinary Action Disciplinary action against her license was then filed. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . To SEARCH and find an individual, press Control and 'f' keys, and type in name. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Undisputed failure but most likely at-risk, not reckless, behavior. Georgia: Nursing Board Tracker - ProPublica 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. However, was the Boards action fair and just in this situation? To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. %PDF-1.5 % Accountability for not following the five rights. and nurses. TN <> 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 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. 2023 Institute for Safe Medication Practices. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Board of Nursing. A nurse can be disciplined for "unprofessional conduct, and negligence, 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. 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. 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. Every state and territory in the US set laws to govern the practice of nursing. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. 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. endstream endobj 1407 0 obj <. 1 0 obj July 23, 2021. 1:00 p.m. Call to Order Board Meeting However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 5200 Butler Pike hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. .`jh L@ b Survey of Advanced Practice Registered Nurses Disciplinary Action The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. Nursing Disciplinary Action Explained | NurseJournal.org PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber Nurse did not verify that the proper medication was removed from the ADC. Select Begin Here For Sign-up under New User to create your account. Available for institutions RaDonda's criminal trial is scheduled to begin on . There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. Hospital settles with patients family, requiring them to not speak about the error publicly. In response to the whistleblower, CMS conducts a surprise hospital inspection. The boards are also responsible for the investigation of alleged violations of the Practice Act and rules and are responsible for the discipline of licensees who are found guilty of such violations. Unreasonable expectations. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. This timeline will help. More warnings would not have changed her performance.. Nurses alleged failures and unanswered questions about the event. Although many questions regarding RaDondas alleged failures and the event remain unanswered (Table 2), the Board still voted unanimously to strip RaDonda of her nursing license and levy the full monetary penalties allowed, noting that there were just too many red flags that RaDonda ignored when administering the medication. 0 ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Board actions may include: Fine or civil penalty. 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. July 13, 2020 Vaught's criminal trial is scheduled to begin. As a primary source equivalent the data is provided directly from the boards of nursing. Nursing Practice Act - StatPearls - NCBI Bookshelf Discipline | NCSBN Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. PDF DISCIPLINARY ACTION REPORT - Tennessee Receive the monthly Disciplinary Action Report by e-mail. Find Your Nurse Practice Act. 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. 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. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. 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.
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