1:00 p.m. Call to Order Board Meeting <> 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. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv Currently, the annual rate of discipline on a nursing license is less than one percent. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) %PDF-1.7 Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. 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. License action type by Tennessee nursing professional. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. 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. `g"H>O|oD)svT>VZ9,VP{PVy9[K. The mission of each board is to safeguard the health, safety and welfare of . 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. U.S. 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. Monday, May 1, 2023 . The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. You must be logged in to view and download this document. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. Nurse administers IV vecuronium instead of Versed (midazolam). On September 27, 2019, in a stark reversal of a 2018 decision to take no licensing action against the nurse, the TN Board of Nursing filed disciplinary action against RaDonda that focused on three violations: Unprofessional conduct related to nursing practice and the five rights of medication administration, Abandoning or neglecting a patient requiring nursing care, Failure to maintain a record of interventions. 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. Disputed failure. endobj Nurse did not verify that the proper medication was removed from the ADC. 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. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Hospital settles with patients family, requiring them to not speak about the error publicly. When I started being a nurse, I told myself that I wanted to take care of people the way I would want my grandmother to be taken care of. <>/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>> Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. However, this failure is substantively unimportant relative to the wrong drug error. 4 0 obj All rights reserved. The court for Tennessee professional licensing is the Administrative Procedures Division. ); 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). (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). endstream endobj 1407 0 obj <. Undisputed failure but most likely at-risk, not reckless, behavior. Serious Disciplinary Actions States. Find Your Nurse Practice Act. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. Receive the monthly Disciplinary Action Report bye-mail. 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. Accountability for not following the five rights. 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). THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Plymouth Meeting, PA 19462. 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. Together the NPA and rules/regulations guide and govern nursing practice. 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. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 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. 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. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. 2023 Institute for Safe Medication Practices. Dispositions of paid claims shall be reported in a minimum of three (3) graduated categories indicating the level of significance of the award or settlement. Lack of a thorough investigation. In response to the whistleblower, CMS conducts a surprise hospital inspection. National Council of State Boards of Nursing, Inc. All Rights Reserved. endstream endobj startxref 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. Undisputed failure but most likely human error, not reckless behavior. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Disputed failure. Comprehensive information on protecting one's . 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. 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. @3Mh?d+Nu*%5l(U9{rRA>@l=ph See Table 1 for a more detailed timeline of events. endstream endobj startxref Undisputed failure but most likely at-risk, not reckless, behavior. Contact Info Montana State Board. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. Nashville Tennessean. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Date of Meeting: May 1, 2023 . To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. Request monthly Disciplinary Action Report by e-mail. 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. 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. 0 If the after a thorough investigation, the BON determines there is sufficient basis that the nurse violated the act or regulations, the BON may take disciplinary action on the nurses license. The standards are very broad. 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. Failure to consider the significant contribution of system failures. Professional nursing license action report. Nurse could not carry out the physicians order to repeat the first dose if insufficient because she did not monitor the effectiveness of the first dose. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . 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 information on this website is for general information purposes only. 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. 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. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". The Board has continued to promote a transparent disciplinary process. Listings are sorted by the year of original Board action issued then by last name, first name. Nurse retrieved a nonurgent medication from the ADC via override. The state's duty to protect those who receive nursing care is the basis for a nursing license. Nurse did not verify that the proper medication was administered to the patient. 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 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.
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