e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Nurse failed to document vecuronium administration to the patient in the EHR. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ 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. 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. and nurses. Board of Nursing Complaint Process: Investigation to Resolution. Practitioner Profiles - Tennessee Nothing on this site should be taken as legal advice for any individual For example, in the case of suspected theft or misappropriation, were there other professionals or employees present who had access to the alleged misappropriated items? Disciplinary Action. 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. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. Click here to go to the live stream site. 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; Discipline | NCSBN Read our recipe for investigating nursing boards' oversight . Monday, May 1, 2023 . (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Nursys Listed below are the meetings held for the past year. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. License Verification (Nursys.com) | NCSBN 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 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). 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. Detailed information about disciplinary . 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. Nursys is the only national nurse licensure and disciplinary database. To SEARCH and find an individual, press Control and 'f' keys, and type in name. Without your 214 2nd Avenue N. TN We believe this is what happened here. The nurses license verification is available immediately to the endorsing board of nursing. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Listings are sorted by the year of original Board action issued then by last name, first name. The court for Tennessee professional licensing is the Administrative Procedures Division. Believing the best in everyone, ISMP has faith that the TN Board of Nursing likely had the right, albeit misguided, intention to protect the citizens of TN. When a BON disciplinary process is based on substance use disorder tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. The Office of Consumer Right to Know is charged with seeking and collecting this information and providing it to consumers via the Departments web site. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. Please secure your User ID and Password for future use. 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. C. omplaints to nursing boards can come from . See what boards of nursing are currently participating. 1432 0 obj <>stream Map & Directions [+]. Serious Disciplinary Actions States. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. 214 2nd Avenue N., Georgia: Nursing Board Tracker - ProPublica Nurse retrieved a nonurgent medication from the ADC via override. 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. See Table 1 for a more detailed timeline of events. 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. Patient involved in medication error is withdrawn from life support and dies. The information on this website is for general information purposes only. `g"H>O|oD)svT>VZ9,VP{PVy9[K. Montana: Nursing Board Tracker - ProPublica 2 0 obj TDH Newsroom. A payment in settlement of a medical malpractice action or claim should not be construed as creating a presumption that medical malpractice has occurred. (Pending malpractice claims shall not be disclosed by a board to the public. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. 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" Plymouth Meeting, PA 19462. 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. Table 2. 1419 0 obj <>/Filter/FlateDecode/ID[<7C1E6885F79A2840B3CD3D4380937611><607411345D04C24E89F3B328005C117C>]/Index[1406 27]/Info 1405 0 R/Length 73/Prev 82019/Root 1407 0 R/Size 1433/Type/XRef/W[1 2 1]>>stream Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . 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. Contact the board at (615) 532-5166. TN Board of Nursing's Unjust Decision to Revoke Nurse's License Date of Meeting: May 1, 2023 . Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. A nurse can be disciplined for "unprofessional conduct, and negligence, Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. %%EOF 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. Disciplinary Actions Log | North Carolina Board of Nursing Make a User ID that you can remember, such as your email address. National Council of State Boards of Nursing, Inc. All Rights Reserved. @3Mh?d+Nu*%5l(U9{rRA>@l=ph . The Board has continued to promote a transparent disciplinary process. Select Begin Here For Sign-up under New User to create your account. If you applied for initial license online, you can use the same account to renew your license. endobj .`jh L@ b {dhF`g)Ut9`6XX:WaVUR!@Z! RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. License action type by Tennessee nursing professional. 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. 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. 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. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. You must be logged in to view and download this document. PDF Professional Licensure: Investigation and Disciplinary Action endstream endobj startxref Undisputed failure but most likely human error, not reckless behavior. _X_\~?Map0j).,XxzZ(uJ@ X{ R@-npXC +G1#!$>Wwo^-!,${W'/7$ A@B`\mu)B8@afs@6Aad&@r6[K0(+hTR]rJL|yC .=okDYp B',zR5dbdG~8hy.3a6zt #x^h%~L7 fUFA@eRiM9X:0&z-j>@95_N6lxPoYK{T#9nHZ"ip]>3>U]S 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. Filing Complaints and Researching Disciplinary Actions. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. 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 Receive the monthly Disciplinary Action Report bye-mail. 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. endobj She said through tears at the hearing, I wont ever be the same person. Board of Nursing. Disciplinary Actions Taken by the Board - Oregon Virginia Board of Nursing - Disciplinary Proceedings 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. Available for institutions PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. The court for Tennessee professional licensing is the Administrative Procedures Division. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Nurse administers IV vecuronium instead of Versed (midazolam). 2023 Institute for Safe Medication Practices. endstream endobj 1407 0 obj <. Every state and territory in the US set laws to govern the practice of nursing.