These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. (2) In order to be issued a certificate of fitness as a nurse practitioner with . 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. Lack of a thorough investigation. PDF Professional Licensure: Investigation and Disciplinary Action Complaints - Tennessee After discussions on this topic, the nurse did not think she had a duty to monitor the patient. Were they monitored and by whom and for how long? 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. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. Hospital settles with patients family, requiring them to not speak about the error publicly. 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. The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. 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. 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. 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. Board members, with few exceptions, are appointed by the Governor. Time: 1:00 p.m. C.T. 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. DISCIPLINARY ACTION REPORT . Suite 400, Information Required to be Reported on Practitioner Profiles. The court for Tennessee professional licensing is the Administrative Procedures Division. 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. The mission of each board is to safeguard the health, safety and welfare of . As a primary source equivalent the data is provided directly from the boards of nursing. These laws are defined in the Nursing Practice Act (NPA). Nashville, TN 37201. National Council of State Boards of Nursing, Inc. All Rights Reserved. Take disciplinary actions as necessary to protect the public from unsafe nurses. 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. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Date of Meeting: May 1, 2023 . Listed below are the meetings held for the past year. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Disciplinary Actions - New Mexico Board of Nursing All rights reserved. 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. 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. Failure to consider the significant contribution of system failures. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. The state's duty to protect those who receive nursing care is the basis for a nursing license. Listings are sorted by the year of original Board action issued then by last name, first name. Nurse did not verify that the proper medication was removed from the ADC. Tennessee: Nursing Board Tracker - projects.propublica.org Request monthly Disciplinary Action Report by e-mail. 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 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. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). 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. However, was the Boards action fair and just in this situation? 7oM~/dc`xb7T206 )5F{w0Q ( She said through tears at the hearing, I wont ever be the same person. Nashville, Unreasonable expectations. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Please secure your User ID and Password for future use. hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 4 0 obj This timeline will help, Medication Safety Officers Society (MSOS). The Division of Health Related Boards provides administrative support to the boards, committees, councils and one registry that are charged with the licensure and regulation of their respective health care professionals, as well as the Office of Consumer Right to Know. Nursing Practice Act - StatPearls - NCBI Bookshelf e-Notify Get free license expiration and status updates via email Nashville Tennessean. 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. 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. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. 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. Undisputed failure but most likely at-risk, not reckless, behavior. 466 0 obj <>stream Board revokes the nurses professional license and fines her $3,000. Health Professionals Boards Disciplinary Actions - Tennessee Detailed information about disciplinary actions is available on . National Council of State Boards of Nursing, Inc. All Rights Reserved. But mistakes were made. 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. Institute for Safe MedicationPractices 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. 1:00 p.m. Call to Order Board Meeting Virginia Board of Nursing - Disciplinary Proceedings 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. Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Nurses alleged failures and unanswered questions about the event. 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. 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. 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. 1432 0 obj <>stream 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). Board of Nursing Complaint Process: Investigation to Resolution. Disciplinary action taken by the institution or organization if action pertains to the Board's grounds for disciplinary action (see related content below) Minnesota Statutes Section 148.261 . 0 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. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". TN Board of Nursing's Unjust Decision to Revoke Nurse's License Information for health professionals regarding the COVID-19 response. Below is a list of actions taken in March 2021. Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. 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" %PDF-1.7 Contact Info Georgia State Board. Georgia: Nursing Board Tracker - ProPublica This page has information and updates on nursing boards and regulation specific to Georgia. endstream endobj startxref You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 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. Adapted from: Kelman B. If you applied for initial license online, you can use the same account to renew your license. Disciplinary action against her license was then filed. nunsirg ce nli es. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . <> Find Your Nurse Practice Act | NCSBN Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . How to report patients abusing TennCare benefits. 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. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Select Begin Here For Sign-up under New User to create your account. %PDF-1.6 % 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. RaDonda Vaught's trial has ended. This timeline of the case explains
