A guest blog by Evan Brown

Nursing boards take public health very seriously. In the interest of protecting public health, most boards take extra precautions to make sure that nurses licensed in their state have a proven track record of delivering excellent care. This includes a critical examination of nurses’ personal and professional histories.

Although you may be thinking that whatever happened was outside of work, the boards take the position that you are a nurse 24/7.

In most states, a blemish on one’s license or criminal record will not automatically bar a nurse from licensure of practice. The nursing board instead will conduct an investigation and make a decision in light of the circumstances at the time. In order to conduct an investigation, nursing boards need to be aware that an incident occurred. For this reason, nursing boards across the country have created self-reporting regulations for nurses to bring their criminal and disciplinary histories to the board’s attention.

Every nursing board asks about criminal and disciplinary history in its initial application for licensure and again on renewal. Boards differ in terms of what infractions must be reported. In general, any arrest, misdemeanor, felony, or plea of nolo contendre (an acceptance of the conviction without an admission of guilt) must be reported. Sometimes nurses must even report expunged convictions. Few require nurses to report minor traffic violations. When applying for licensure in a new state, every board also asks about prior and current disciplinary action by another board of nursing on the applicant’s license. An affirmative answer to any of these questions will often require the submission of court records and a written explanation of the event.

What about criminal convictions that occur after a nurse has received his or her license? When should these convictions be reported to the board? At minimum, every state board requires nurses to report such incidents when they renew their license. However, most states require self-reporting closer to the time of conviction. These timeframes range from “immediately” to between 10 and 90 days. One state, Arizona, requires notification of an arrest within 10 business days.  Only in Massachusetts, Rhode Island, and Virginia is there no duty to self-report. These states often rely on automatic police and court reporting to the board, it is still wise to self-report.

It is always best to self-report as soon as possible, even if the board neither requires a self-report yet nor at all. Doing so demonstrates honesty and initiative, which an appreciative board may take into account when determining a response. Seeking rehabilitation or counseling, performing community service, and other voluntary measures of atonement can also help the board look more favorable on your case.

I’m sure you’ve read in the media or on my blog about Nurse RaDonda Vaught who has been charged with reckless homicide for an inadvertent medication error.

In a news article released by hospitalwatchdog.org, they described what Vanderbilt University Medical Center (VUMC) did not do that could have prevented this tragic incident.

Whenever the Centers for Medicare & Medicaid Services investigates, they prepare a deficiency report.  When a deficiency report is received by a facility, they must respond to the deficiencies and offer a plan of correction to remedy the deficiencies.

“The real issue in this case is that there were no effective systems in place to prevent or detect the accidental selection, removal, and administration of a neuromuscular blocker that had been obtained via override.”

As in the past, I am in no way saying that Nurse Vaught’s actions were proper.  My position is that this is a medical malpractice rather than a criminal matter!  However, VUMC did not have her back and fired her rather than fix the system issues that contributed to this error.

Once CMS investigated, VUMC had to put systems in place to prevent these types of problems.  In VUMC’s Plan of Correction, the facility has agreed to:

1.         Take vecuronium off override.  Had vecuronium been taken off override, Nurse Vaught would never have been able to access this medication.

2.         Implement bar coding verification in the radiology department.  Like most areas, if one takes a medication out of the Pyxis or the med cart and gives it to a patient, the medication’s barcode is scanned.  This ensures that the patient is receiving the correct medication.  In this situation, if Nurse Vaught would have been able to scan the patient’s wrist band, it would have alerted her that this was not an ordered medication for this patient.

3.         Implement the second nurse verification in the radiology department.  Having a second nurse review and verify the accuracy of the order and the medication, this would have prevented the death of Charlene Murphy.

4.         Require a nurse to enter “PARA” in the automatic dispensing cabinet (ADC).  In order to obtain a paralytic drug from the ADC, a nurse must first type in the letters P-A-R-A.  This too would have prevented Ms. Murphy’s death.

5.         Implement policies that did not previously exist for monitoring high risk medications such as versed or vecuronium.  It is surprising that prior to the incident with Ms. Murphy, VUMC did not have policies and procedures to monitor such dangerous medicines.  They now do.

The article goes on to question whether the District Attorney (DA) has a conflict of interest because the DA, Glenn Funk, has multiple, personal and professional relationships with Vanderbilt University.  He is an Adjunct Professor at the Vanderbilt School of Law, served on the Vanderbilt Kennedy Center Leadership Council and he and his wife are members of the Next Step Advisory Council at the Special Education Department at Vanderbilt’s Peabody College.

Criminal prosecution will not provide safer medicine.  It is a system issue that needs to be addressed.

It should go without saying that Vanderbilt and VUMC attempted to cover up this tragedy and the Murphy family did not even know of the situation for almost a year after the incident.  My heart goes out to Ms. Murphy’s family, to RaDonda Vaught and to all of the nurses who everyday put their health, their lives, their well-being on the line in the service of others.

One of the hardest things about representing a nurse before the Board is that anyone can make an allegation against the nurse and report it.  Many times, these can be a “he said … she said” situation.

“The nurse gave me only 1 type of codone instead of 2!”  “The nurse held my arms so tight; I got a bruise!”  “The nurse took money from my wallet!”  And the list goes on and on.

It is so sad that these allegations are made and the ones in the previous paragraph are just from patients.  But coworkers can make allegations too.  “I saw her drop a medication on the floor then administer it to a patient.” “My coworker was rude to a patient.” When a hospital hears about allegations from patients and staff about nurses, they are going to be concerned.  In my experience, the facility usually takes the patient’s side and even if the complaint is unsubstantiated, frequently the nurse will lose their job.

How can you protect yourself from these allegations?  Well, to be honest, I don’t have a magic answer.

I think part of the problem is the culture of nursing.  The Board’s job is to protect the public and not the nurse.  The hospital thinks the nurse’s job is to promote good customer service.

About the only advice I can give would be that if you have any concerns about taking care of particular patients, voice those concerns and see if you can have your assignment changed.  It is not worth it to put yourself in a situation where a complaint can be made against you.

I frequently hear from nurse clients that a particular coworker or manager, “had it out for me.”  Should you ever feel like you are in one of situations, it is better to leave the facility and find another job rather than to face an allegation.

I think it would be great if the criminal standard of being “beyond a reasonable doubt” would be applied to a complaint.  However, it’s not.  The Board can listen to hearsay and if there’s any concern about safety to the public, they will take action.  It doesn’t seem quite right but that is what happens.

I think the best way to prevent circumstances is to avoid them.  If you feel that you should have a witness while caring for a particular patient or when you are with a coworker, bring someone with you.  Then, if you are ever called on the matter, you have some protection.  Your license is too important.

How would you protect yourself in these types of situations?  Have you ever found yourself at the center of such matter?  What did YOU do?  Let us hear your comments in the space below.

These days cameras are everywhere.  In fact, in the United Kingdom, any person can be seen on camera at least 300 times every day as the devices are everywhere.  Every time you’re on the street, every time you enter a store, restaurant or bank, drive into a public garage … anywhere and everywhere the chances are likely that a camera is looking at you.  And now they are making their way into hospitals around the world.

A recent case in San Diego against Sharp Hospital, Administration put 3 motion detector cameras on their anesthesia medication cart because someone was stealing propofol.  However, the cameras did not shut off when there was no motion and it happened to be in an OB surgical suite where women were having babies by C-section and GYN type surgeries where the patients’ genitalia were exposed.  These patients, some of whom where unconscious, were being videotaped without their knowledge or consent.  The hospital no longer has 3 of the servers with the videos and is unsure if the hard drives were properly erased.  This is scary and a true invasion of privacy as well as a violation of HIPAA. 

There are also ICUs where patients consent to be monitored on video tape called E ICU.  Video cameras are sometimes located in public areas of hospitals and health care facilities.

I think cameras can help … and they can hurt.

The idea of having cameras at the Pyxis is to see who takes medication and whether medication is properly wasted.  This can be helpful to show your properly wasted medication with a witness or it can hurt if you forgot to sign out that you administered the medication.  If your facility does have a camera at the Pyxis, I would recommend that you administer the ordered medication to the patient right away, document that on the MAR and then immediately waste the medication in front of the camera with a witness so there can be no question about you properly deposing of the medication.

Cameras also can be a disservice because they capture images at only one angle and you cannot get the true 3-D picture.  If you go to break up an altercation with patients in a hall, what the video shows will depend at which the camera views the scene.  Or, if you are providing care to a patient on video, it may be misconstrued that you are being rough with a patient.  Things aren’t always as they seem at one angle.  Sometimes you need multiple angles.

I do have concerns about patients’ privacy on video.  I think sometimes facilities will give you a paper and ask you to sign it and most will do as they are told but not bother to read it.

In some respects, cameras can be a blessing and help a person if the footage is kept and sometimes it can be a curse.

What are your thoughts on being videotaped doing your job?