Oxycontin’s 12-Hour Problem: L.A. Times’ Investigation, and What Doctors and NPs Need to Know About Prescribing the Drug

oxycontin-470x260Earlier this summer, the L.A. Times reported on its investigation into Oxycontin, and the results aren’t pretty: the Times found that Oxycontin’s main selling point, that it lasts for 12 hours, is not supported by clinical research. In spite of this, the Times found overwhelming evidence indicating that not only did Purdue Pharma (the marker of Oxycontin) have knowledge of Oxycontin wearing off well before the 12-hour mark, Purdue intentionally repressed this knowledge from doctors, patients, and the FDA for the past 20 years.

The L.A. Times investigation reports the following:

Purdue Pharma submitted falsified research numbers to the FDA when they gained approval for Oxycontin in 1996, stating that the drug treats pain for 12 hours. The problem with Purdue’s claim is that Oxycontin only treats pain for roughly half that time.

Purdue Pharma, despite continual feedback for the past 20 years from patients, doctors, and their own pharmaceutical reps that the drug wears off long before the 12 hour mark, has continued to market the drug as a “12 hour drug,” to give themselves a competitive advantage over other pain medications. The only problem with this, despite the obvious lying to consumers part, is that prescribing a strong narcotic for 12-hour cycles, when it only relieves pain for 6-8 hours, actually sets up patients for addiction due to dangerous pain relief/withdraw cycles.

Further, Pharma reps encouraged doctors to stick to the 12-hour prescription cycle, but simply prescribe higher doses. A study from Canada showed that this method of prescribing resulting in an overdose for 1 out of every 33 patients. It’s hard to imagine, but this study shows that Oxycontin prescribed in the method encouraged by Purdue Parma reps is more likely to kill a patient than anything else (really, anything else) in the world.

Why does this matter?

The prescription drug epidemic is HUGE in America. It’s a public health crisis, particularly so in the Southeast (where my practice as an attorney is based). It’s a difficult problem to understand, particularly the big question–who is at fault? People who simply like to abuse drugs? Doctors who are prescribing inappropriately? A culture as a whole that views “pain” as a problem to be eradicated by their healthcare provider? Now we have a small answer to this huge, multi-faceted question–who is at fault? A drug company–who has made billions for the past 20 years–that knowingly instructed doctors (WITH the FDA’s approval) to prescribe medication at a dangerously high dosage, and at intervals that all-but set up patients for addiction–at the low end of the spectrum–and death at the high end.

What can doctors and nurse practitioners do in response to this information?

  1. As always, monitor your patients, and realize that simply because a medication is approved for treatment by the FDA does not mean that it is the right treatment for YOUR patient.
  2. Despite the necessary and often beneficial role that pharmaceutical sales reps play in educating physicians and NPs about new technology and medication available, be mindful that these sales reps are in your office or at your hospital for their own financial gain. It is incumbent that healthcare providers not rely on sales reps as your sole source of information about medications that you may be prescribing.
  3. Finally, (and hopefully, most obviously), be mindful of your prescribing of Oxycontin. Monitor each patient individually for his or her feedback on when the drug wears off, and consider switching treatment based on your patient’s feedback. Do not rely on your sales reps, or even the FDA to know what is best for your patients. Regardless of what your opinion is on the role of prescription writers in the current opioid epidemic in America, we can all agree that doctors and nurse practitioners have a responsibility and an opportunity to be a part of the solution.

Comments or thoughts? Please feel free to comment below, or contact me directly at [email protected].

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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The Hardest Pill to Swallow

Dr. Tracy Jackson discusses chronic pain in her May 2016 TEDx Nashville event. Dr. Jackson, a Vanderbilt physician, researches and works in the chronic pain management field, and she discusses how and why the healthcare system’s current approach to chronic pain management is failing patients–and society as a whole–in her TEDx talk.

Why does this matter? For healthcare providers, particularly those in the southern part of the United States, the prescribing of controlled substances for the management of chronic pain has become a hotly debated and highly regulated activity. For the protection of one’s license, and the safety of one’s patients, it is incumbent on healthcare providers to educate themselves on the most effective and safe ways to treat chronic pain.

For those who aren’t healthcare providers? It still matters. Opioid overdose is the number one cause of accidental death in the U.S. (See, Tedx Talk, 8:10). Let that sink in for a minute. Even if pain management and the use of opioids does not affect you professionally as a health care provider, it likely has or will affect you or someone you love personally. It is incumbent upon all of us to be aware of what we are putting in our bodies, and how it effects us.

Main Take Aways From ‘The Hardest Pill to Swallow:’

  1. Chronic Pain is the # 1 presenting complaint to U.S. doctors, the #1 reason people are out of work, and it costs the U.S. economy up to $630 billion dollars a year. It’s a big deal, for the individuals suffering from it, and for our U.S. economy as a whole. (See 1:20).
  2. Kids often get tummy aches when they are stressed or trying to avoid a stressful situation–right?

    “Kids describe a physical symptom based on an emotional issue, yet as adults we continue to deny that pain from mental stress can manifest as pain in the body. When did we forget the tummy ache?”

    (See 5:02).

  3. Pain pathways, sleep pathways, and mood pathways are all interconnected–we cannot separate them. If one goes awry, all pathways will be effected. (See 5:45).
  4. The hardest pill to swallow is that there is no quick fix–but there is a fix. (See 15:00).
  5. Each of us can make a difference by admitting that stress and lifestyle choices can contribute to and even cause chronic pain at any age. We can hold ourselves and our loved ones accountable to seeking real and durable relief, even when a pill is available on every corner. (See 17:10).

Take 18 minutes out of your day to watch Dr. Jackson’s TEDx Talk–I promise, it’s well worth your time. Feel free to comment below with any thoughts or responses, and as always, feel free to reach out to me directly–[email protected]

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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Investigated by the Department of Health or Facing Licensure Discipline? You Have Options.

Licensure Investigation: How and Why?

The Department of Health in the state where a provider is licensed has a duty to investigate valid complaints against healthcare providers. Complaints against healthcare providers can be made anonymously, and most states, like the Tennessee Department of Health, have an landing page on their websites that makes it easy to file a complaint. If the complaint is frivolous, such as “This doctor is a jerk,” the complaint will be reviewed and likely dismissed by staff at the Department of Health without further inquiry. If the complaint is more serious, such as “This doctor is overprescribing narcotics to his patients,” then the complaint will likely be investigated further.

Once a complaint has been deemed serious enough for investigation, a Department of Health investigator will be assigned to make an inquiry into the complaint. This will likely begin with a telephone call or letter addressed to the health care provider who the complaint is about. If an investigator from the Department of Health contacts you, you have the right to be represented by counsel. At this point, most healthcare providers will be very upset, concerned, and frustrated to find out a complaint has been filed against their license. As such, retaining counsel who can represent them with stoicism throughout the investigation will likely result in less stressful and more productive interactions with the Department of Health through the investigation.

The Investigation Has Concluded: Now What?

Typically after meeting with an investigator, the Department of Health will inform a healthcare provider about the outcome of the investigation within 3-9 months. The outcome of the investigation is one of the following: (1) the complaint is dismissed; (2) the healthcare provider is sent a letter of concern or a letter of warning, and the case is closed; or (3) the Department of Health chooses to pursue formal disciplinary action. This formal discipline will be communicated to a healthcare provider in the form of a letter setting forth what the Department of Health determined in the course of their investigation (sometimes referred to as a 4-5-320(c) letter) with an attached “Consent Order” for the healthcare provider to sign and return to the Department of Health within a set number of days.

If you have not yet hired counsel, I recommend hiring an attorney to represent you through the negotiation of any consent order. Most consent orders are negotiable, and even if the proposed disciplinary action seems acceptable to you, your attorney can review the facts in the order to ensure that you are not admitting to any violation of criminal or civil law that would open you up to additional liability.

Hiring An Attorney: Who To Look for, How To Find Them, and Does It Really Make a Difference?

When seeking an advocate to assist you through the investigation and/or discipline of your health care license, it’s important to seek out an attorney with expertise in this area. Just as you wouldn’t hire a dermatologist to perform brain surgery, don’t hire your divorce attorney, or estate planning lawyer to represent you in an administrative action (unless he or she also happens to have a great deal of expertise in administrative law).

How do you find someone experienced in administrative law before your regulatory board (such as The Board of Medical Examiners or The Board of Nursing)? First, you can start by checking with your statewide professional association (for example, the Tennessee Medical Association or Tennessee Nurses Association). Generally most professional associations maintain a list of attorneys for referral. Second, you can independently do your own research by asking other healthcare providers you know, as well as researching online. Third, you may even be able to get a name of an attorney for referral from the administrative staff of your state regulatory board, or the attorney representing the Department of Health. And finally, if you are recently out of medical or nursing school, your professors or mentors from school may be a good source of referral to an experienced administrative attorney.

Having your license investigated or disciplined is generally the most stressful experience of a healthcare professional’s career. Having a competent advocate who can guide you through the regulatory maze, let you know what to expect, and advocate on your behalf makes the process less stressful and invasive in your personal life, and permits you to make informed decisions about how best to proceed.

Bottom line: Licensure investigation or discipline is a highly stressful process, and it’s beneficial to have an advocate guiding and counseling you through the process. If you have any questions or comments, as always, feel free to reach out to me at [email protected]

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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What is the OIG Exclusion List, and How Could it Affect Your Practice?

The Office of the Inspector General (OIG) of the U.S. Department of Health & Human Services maintains a list of healthcare providers who are excluded from participating in Medicare, Medicaid, and all other Federal health care programs. This list is known as the “List of Excluded Individuals/Entities (LEIE)” and it is a BIG DEAL for the healthcare providers who unfortunately find themselves on this list. Inclusion on the list seriously prohibits a provider’s ability to treat patients, as well as their ability to obtain employment opportunities.

For what actions or events will a healthcare provider find themselves on the OIG Exclusion List?

Permissive Exclusions: The OIG has discretionary authority to exclude individuals and entities for the following reasons:

  • Misdemeanor convictions related to fraud or the obstruction of an investigation or audit;
  • Misdemeanor convictions related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
  • The suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence or financial integrity;
  • A provider’s exclusion or suspension under Federal or State health care programs;
  • The submission of false or fraudulent claims to a Federal health care program by the provider;
  • A provider’s default on health education loans or scholarship obligations; or
  • A provider’s role in controlling a sanctioned entity as a manager, officer or owner.

Mandatory Exclusions: The OIG is required by law to exclude individuals and entities for the following reasons:

  • Conviction of Medicare or Medicaid fraud;
  • Patient abuse or neglect;
  • Felony convictions for other health care-related fraud, theft, or other financial misconduct; or
  • Felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

For a complete list, and more details about permissive and mandatory exclusions, see 42 U.S.C.A. § 1320a-7. For more information about the OIG Exclusion list, visit the Office of Inspector General’s website here.

Bottom line: for physicians, nurse practitioners, and other health care providers facing disciplinary charges by their state medical or nursing board, or those healthcare providers facing potential criminal charges, it is important to know that licensure discipline and criminal charges, among other things, could land a provider on the OIG Exclusion list, and lead to an even steeper uphill battle back to the practice of medicine or nursing.

For employers, it is important to know that an entity can face severe penalties for attempts to recover payment from the federal government for patient care performed by an individual on the OIG exclusion list. I recommend that employers check the Exclusions Database prior to hiring new health care providers to determine if potential hires fall on this list, and to avoid potential liability for the organization.

If a provider is currently on the OIG exclusion list, he or she can apply for reinstatement to participate in Federal health programs once the specified period of exclusion ends. To apply for reinstatement, follow the instructions found here.

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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CDC and FDA Add New Guidelines and Regulations Aimed at Curbing Overprescribing of Opioids

The Center for Disease Control and the Federal Drug Administration both recently released new guidelines, from the CDC, and new regulations, from the FDA, aimed at addressing the rising concern about the nationwide opioid epidemic. Not coincidentally, these guidelines and regulations were announced within a week of one another. I think this signals a strong message from the federal government to both state governments and health care providers: if you won’t fix this problem, we will.

CDC’s New Guidelines for Prescribing Opioids for Chronic Pain

Although many states have released their own guidelines for the management of chronic pain (Tennessee’s guidelines, released in 2014, are accessible here), this is the first set of guidelines available nationwide to healthcare providers. The CDC’s guidelines include 12 main recommendations, which include establishing treatment goals with patients prior to starting a patient on opioids, and avoiding concurrent opioids and benzodiazepines whenever possible.

The starting dosage recommendation of 50 mg morphine equivalent will likely result in some push back from providers, but I think this low number indicates how strongly the CDC feels about the riskiness of prescribing opioids at all for chronic pain in patients. Health care providers—physicians, nurse practitioners, and physician assistants—who have the ability to prescribe and who provide care for patients with chronic pain need to ensure that they are properly documenting justification for their medical diagnosis of patients with chronic pain, as well as their chosen treatment of each patient’s chronic pain.

Federal Drug Administration’s Safety Label Changes for Immediate-Release Opioid Pain Medications

The FDA released new regulations last week with required labels on immediate release (IR) opioid pain medication, including a box on IR opioid prescriptions warning about the risks for misuse, abuse, addiction, overdose and even death. These regulations are a follow up to the FDA’s 2013 prescription warnings on extended-release/long-acting (ER/LA) opioids resulting from the FDA’s concern of the risks associated with long acting opioids. Today, the FDA is acknowledging and clarifying that immediate release opioids are also dangerous, and play a persistent role in addiction, abuse, and overdose mortality related to opioid use.

What Do These Guidelines and Regulations Mean?

The CDC’s Guidelines for prescribing opioids and the FDA’s new labeling requirements for IR opioid pain medication indicate concern at the federal level regarding the prescribing of opioids. Healthcare providers who prescribe opioids should be cautious about their prescribing of these medications, and always document to demonstrate the provider’s decision-making in prescribing an opioid, and the patient’s clear medical need for the medication.

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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When Personal & Professional Life Intersection: Notifying Your Licensing Board About your Criminal History

As a licensed professional, it can be difficult to remember that your personal life is not completely separate from your professional life. In the state of Tennessee, health care providers such as physicians, nurse practitioners, and physician assistants are required by law to update their online profiles with the Department of Health regarding criminal convictions, as well as other adverse events.

Here’s the law in Tennessee: Health care providers (defined in T.C.A. § 63-51-102(b)) must update information “required to be reported” to the Department of Health within 30 days after the occurrence of an event or attainment of a status. T.C.A. § 63-51-117(d).

What is information that is “required to be reported?”

  • Criminal convictions for felonies and “serious misdemeanors,” as determined by the Board, within the past ten (10) years;
  • Any final disciplinary action by a licensing board in any state within the past ten (10) years;
  • Any peer review action taken by a hospital resulting in a provider’s loss or restriction of privileges;
  • All health care liability civil court judgments against a provider over a certain threshold (this threshold varies with profession—for example, the threshold to report is $75,000 for chiropractors, but only $50,000 for dentists). (T.C.A. § 63-51-105).

Failure to accurately and timely update the Department of Health could result in civil penalties, disciplinary action, or the inability to renew your professional license. (T.C.A. § 63-51-117(e); T.C.A. § 63-51-118). Be aware of the reporting requirements in your state, and do your best to comply with such requirements in order to avoid fines, discipline, or an inability to renew your license. Further, ensure that your mailing address is up-to-date with your licensing board. Many boards only communicate via snail mail, and updating your address with your licensing board ensures that you don’t miss any important correspondence regarding your license.

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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Don’t Lose Your Job, Too: The Healthcare Provider Disciplinary Process and Your Employer

Alex Fisher and Erin Tolbert, the creator of MidlevelU, discuss the implications of an investigation by a healthcare board, such as the Board of Nursing or the Board of Medical Examiners, on a healthcare provider’s employment. The original article and video, published on MidlevelU, can be found here. Although Erin and Alex discuss the effects of an investigation by a healthcare board in the context of nurse practitioners, the same advice applies to physicians and other healthcare providers.

Investigation by the Board of Nursing

Nurse Practitioners may face disciplinary action in one of two main categories: (1) prescribing and (2) professionalism. Typical disciplinary action for prescribing involves overprescribing, prescribing for patients without proper documentation, and prescribing without appropriate medical justification. By contrast, typical disciplinary actions for professionalism generally involve being dishonest at work, inappropriate relationships with patients, and any other sort of boundary crossing with patients or co-workers.

An investigation by the Board of Nursing, or another healthcare related board, does not necessarily mean a healthcare provider has done anything wrong, or that he or she will face discipline.

Disclosure to Your Employer: When to Wait

Typically, most investigators from the Department of Health and healthcare related boards will not disclosure their investigation of your license to your employer unless the investigator interviews your employer or co-workers as part of his or her investigation, or requests medical records or documentation from your employer. If the investigator has not disclosed the investigation to your employer, it may be best to wait to disclose until the results of the investigation are known–i.e., if the investigation is unfounded and the complaint will be dismissed, or if the healthcare board is planning on pursuing disciplinary action against your license.

Exception: Many hospital bylaws require that a healthcare provider with hospital privileges disclose the status of an investigation against the provider within a certain window of time. Be aware of any hospital bylaws or employer requirements that may require you to disclose the status of an investigation as soon as you become aware of it.

Disclosure to Your Employer: When to Disclose

If your employer has already been contacted by the Department of Health, or otherwise made aware of the investigation by someone else, I recommend disclosing, in a confidential setting, such as a closed-door office, rather than in the hallways of your clinic or hospital, the following to your direct supervisor:

  1. What the complaint was against you;
  2. What exactly is being investigated; and
  3. What the status of the investigation is.

When disclosing the details of the investigation to your employer, I recommend “being honest, and brief.” Crying while discussing an investigation with your employer, or over sharing your feelings or emotions regarding the investigation with your supervisor or co-workers is generally considered unprofessional, and could reflect poorly on you.

In Between Jobs? Read Carefully.

If you are applying for a new job while your license is under investigation, be diligent in carefully reading questions on any job application. One application may request disclosure of any “investigations” into your license, while another application may simply ask for the disclosure of any “discipline” against your license. Be sure to answer appropriately.

Having your license under investigation can be a disconcerting and difficult process, so if possible, I recommend hiring counsel to advocate for you as early as possible in any investigation into your license.

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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Legal Considerations: Prescribing Medications for Friends and Family

Alex Fisher and Erin Tolbert, the creator of MidlevelU, discuss legal considerations to be mindful of when prescribing medications for friends and family. The original article and video, published on MidlevelU, can be found here. Although Erin and Alex discuss prescribing to friends and family in the context of nurse practitioners, the same advice applies to other physicians and other healthcare providers.

100% of Physicians Say They have Prescribed Medication for Friends and Family

Statistics show that prescribing to friends and family members is a common practice among health care providers. Most states do not prohibit writing prescriptions for friends and family; however states require proper documentation to accompany all prescriptions that are written. In addition, most states discourage the practice of writing prescriptions to friends and family members except in emergency situations. It is important to remember that when writing a prescription for a controlled substance, federal law mandates that this must take place in the context of a strict, traditional provider-patient relationship.

Best Practices

In addition to protecting one’s license from future discipline, proper documentation to accompany all prescriptions is an important best practice for health care providers. For example, if a provider is prescribing to someone without taking his or her vital signs or knowing what other prescriptions he or she is on, the prescription written could end up harming the patient. Something else to remember when writing prescriptions: once a provider has written an prescription, he or she has entered into a legal provider-patient relationship with that patient, and the provider could be legally liable for any repercussions of the prescription he or she wrote. For example, if the medication causes drowsiness, and the patient falls asleep while driving and hurts someone, the provider could be liable.

What are the Consequences of Writing Prescriptions to Friends and Family Without Documentation?

The consequences of writing prescriptions to friends and family without documentation can range from a reprimand, required continuing education related to documentation and/or prescribing, and in some cases, revocation of a provider’s professional license. The best way providers can protect themselves from potential discipline by his or her state Board of Nursing or Board of Medical Examiners is to properly document when writing any prescription, and to be cautious about the writing of prescriptions to friends and family.

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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Administrative Law Introduction

Welcome to the Administrative Law blog. Here at Thompson Burton, our administrative law practice routinely represents health care professionals before their respective licensing boards, such as the Board of Medical Examiners and Board of Nursing. This short introductory video is aimed at explaining this practice area both to individuals seeking representation, as well as others seeking to generally understand this practice area at Thompson Burton.

 

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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Nursing Regulations and the Board of Nursing

Alex Fisher was recently asked to speak as a guest lecturer to a class of first year nursing students at Southwest Community College in Memphis, Tennessee, to discuss how nurses are regulated by the Board of NursingAlthough Alex discusses regulations and regulatory boards in the context of nursing, the same regulations apply to other health care providers, including physicians, physician assistants, and pharmacists. Alex discusses the following:

The Purpose of State Nursing Boards

Nurse Boards award licenses to L.P.N.s, R.N.s, and N.P.s, and set forth the educational curriculums and standards for nursing programs in the state. In addition, the Board interprets the statutes and rules related to nursing to determine the appropriate standards of practice, and the Board enforces these statutes and rules when they are deemed to be violated.

The Legal Discipline Process Before a Nursing Board

The Board of Nursing follows a legal process in all cases. Nurses and other healthcare providers have the opportunity to respond to a complaint made against his or her license, retain counsel and conduct their own discovery of the facts. Finally, nurses and healthcare providers have the opportunity to proceed to a contested care hearing before his or her regulatory board, if he or she so chooses.

Ways to Mitigate Potential Licensure Concerns in the Future

The best ways to mitigate potential licensure concerns are discussed herein, and explained in greater detail in the previously published three-part series, ’10 Ways to Avoid Losing your Medical License.’ Part I, Part II, and Part III can be found here.

In conclusion, the Board of Nursing follows a legal process in all cases. Regulatory boards expect healthcare providers to comply with standards of care, and the Boards will take actions to assure public safety. In order to avoid complaints against one’s license, be familiar with your state rules and regulations, and comply with best practices to avoid licensure discipline.

Alex Scarbrough Fisher

Alex Scarbrough Fisher is an associate attorney at Thompson Burton PLLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.

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