The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. a number of sources. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Contact the board at (615) 532-5166. 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. 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. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) Disciplinary Action Report Page 1 of 11 . Contact us with any comments or questions. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Undisputed failure but most likely at-risk, not reckless, behavior. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. endobj 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. Information Required to be Reported on Practitioner Profiles. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Nurse retrieved a nonurgent medication from the ADC via override. Map & Directions [+]. and nurses. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. 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. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. 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. 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. Nashville, 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. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. The state's duty to protect those who receive nursing care is the basis for a nursing license. Without your 214 2nd Avenue N. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. 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. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. Accountability for not following the five rights. Adapted from: Kelman B. 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. Take disciplinary actions as necessary to protect the public from unsafe nurses. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . You must be logged in to view and download this document. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". TDH Newsroom. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. For Institutions. If you applied for initial license online, you can use the same account to renew your license. Nashville, TN 37201. Contact Info Georgia State Board. endstream endobj startxref 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\-; Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. 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). Were they monitored and by whom and for how long? Please include your name, title/position, organization name, office phone and . Speak with an attorney as soon as possible. The prosecutor acknowledged that the hospital had various system failures that contributed to the error; however, he stressed that the Board is not here to look at the system and is instead looking at individual conduct. Thus, the Board judged RaDondas behavior in isolation of the contributing system failures. 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. Undisputed failure but most likely at-risk, not reckless, behavior. Name of Board: Tennessee Board of Nursing . Nursys is the only national nurse licensure and disciplinary database. 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. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. 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 But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. % The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. or viewing does not constitute, an attorney-client relationship. Below is a list of actions taken in March 2021. 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. 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. 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). In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. Receive the monthly Disciplinary Action Report by e-mail. 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. {dhF`g)Ut9`6XX:WaVUR!@Z! 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. You must have JavaScript enabled to use this form. Listings are sorted by the year of original Board action issued then by last name, first name. How to report patients abusing TennCare benefits. National Council of State Boards of Nursing, Inc. All Rights Reserved. Undisputed failure. 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. Place: Electronic Meeting / Poplar Room . 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. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> <> Board revokes the nurses professional license and fines her $3,000. %PDF-1.5 % The standards are very broad. hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. 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 is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. 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. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . Nurse administers IV vecuronium instead of Versed (midazolam). Lack of a thorough investigation. Detailed information about disciplinary actions is available on . 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. 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. 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. 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. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. All rights reserved. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. 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). Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. C. omplaints to nursing boards can come from . Plymouth Meeting, PA 19462. 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? 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. Please include your name, title/position, organization name, office phone and email in your request. 1406 0 obj <> endobj 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 . This page has information and updates on nursing boards and regulation specific to Montana. The court for Tennessee professional licensing is the Administrative Procedures Division. Nurse did not verify that the proper medication was administered to the patient. Disciplinary action against her license was then filed. Suite 400 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. Table 2. Nurses alleged failures and unanswered questions about the event. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. 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.
Space Engineers Connector Not Transferring,
Wayne Newton Grandchildren,
Is It Legal To Kill Feral Cats In California,
How Many Brands Do Footasylum Sell,
Articles T