. endstream endobj 1407 0 obj <. %PDF-1.7 endobj Find Your Nurse Practice Act | NCSBN 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? 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. Patient involved in medication error is withdrawn from life support and dies. 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; Make a User ID that you can remember, such as your email address. %%EOF 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. 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. The mission of each board is to safeguard the health, safety and welfare of . Undisputed failure but most likely at-risk, not reckless, behavior. RaDondas criminal trial is scheduled to begin on March 21, 2022. Please click the link below to access the licensure renewal page. 2 0 obj TDH Newsroom. PDF Disciplinary Action Report Page 1 of 18 - Tennessee Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). PDF Disciplinary Action Report Page 1 of 14 - Tennessee Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. While nursing mistakes or misconduct may lead to other consequences, such as employer reprimands, terminations, civil suits, or criminal charges, nurse disciplinary action directly affects a nurse's license. 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. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. 1:00 p.m. Call to Order Board Meeting As RaDondas defense attorney said during the hearing, Rather than revoking this good nurses license, there needs to be another way. If we dont find it, we risk jeopardizing the opportunity to recruit talented people into the healthcare fieldthey wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. 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. 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. Disciplinary Actions Taken by the Board - Oregon According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. The same Board member said a reasonable nurse would have brought appropriate monitoring equipment and oxygen to radiology to monitor the patient, despite repeated discussions with the primary care nurse who explicitly noted that no monitoring was required. <> These laws are defined in the Nursing Practice Act (NPA). Below is a list of actions taken in July 2020. 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. Lack of a thorough investigation. e-Notify Get free license expiration and status updates via email Nursing Practice Act - StatPearls - NCBI Bookshelf Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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 . National Council of State Boards of Nursing, Inc. All Rights Reserved. hbbd``b`:$gP " `v nb-W&FV^ 'F 5200 Butler Pike You can draw your own conclusions by viewing the 2-day hearing, but the following is what ISMP finds most disturbing and unjust about the Boards decision to revoke RaDondas license: Significant outcome bias. The nurse was surprised that the medication was a powder, so she turned the vial over quickly to look at the reconstitution directions on the back of the label, without looking at the front of the label (and product name). PDF Professional Licensure: Investigation and Disciplinary Action Speak with an attorney as soon as possible. The court for Tennessee professional licensing is the Administrative Procedures Division. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. The nurses license verification is available immediately to the endorsing board of nursing. here are three Nursys services publicly available via nursys.com: e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Below is a list of actions taken in NOVEMBER 2021. The Board has continued to promote a transparent disciplinary process. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! 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. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. All rights reserved. Board revokes the nurses professional license and fines her $3,000. % Monday, May 1, 2023 . Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. 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. 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. hb```\^ !0!U[j|}+Iv0H/\K Suite 400 If you are threatened with the loss of your professional license, you must take prompt action. 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. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. 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. 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. National Council of State Boards of Nursing, Inc. All Rights Reserved. Disciplinary action against her license was then filed. TN Board of Nursing's Unjust Decision to Revoke Nurse's License 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. 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. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. We believe this is what happened here. %PDF-1.5 % In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . (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 information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. When a BON disciplinary process is based on substance use disorder 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. `g"H>O|oD)svT>VZ9,VP{PVy9[K. 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. Contact Info Montana State Board. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. 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. endstream endobj startxref DISCIPLINARY ACTION REPORT . Comprehensive information on protecting one's . Below is a list of actions taken in March 2021. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. 63-7-115. 2023 Institute for Safe Medication Practices. Health Professionals Boards Disciplinary Actions - Tennessee Place: Electronic Meeting / Poplar Room . 466 0 obj <>stream Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. 437 0 obj <> endobj 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. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. Tennessee Department of Health Publications. 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. The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. 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. Reporting Obligations - Minnesota Board of Nursing Discipline | NCSBN or viewing does not constitute, an attorney-client relationship. 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. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. 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. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions.
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