Another Fail by TN BON

Published Apr 16, 2022

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Once again the Tennessee Board of Nursing has failed to protect patients. In July 2021 Johnson City Medical Center in Johnson City, TN, found that someone had tampered with vials of dilaudid and returned the vials to the omnicell. The tampered vials were linked to Jaqueline Brewster, a travel nurse.

“She was removing the Dilaudid and replacing it with another substance that looked clear like Dilaudid, and replacing the vials in the Omnicell system,” Levine said. “One of our other nurses noticed that something looked different in one of the vials and notified the pharmacy immediately.”

Ballad Health fired Brewster and alerted law enforcement and the Tennessee Department of Health, according to a statement from the company. It sent five Dilaudid syringes to the Tennessee Bureau of Investigation’s crime lab, which confirmed the amount of medication within was “inconsistent with the manufacturer’s label,” according to the nursing board documents."

Ballad Health notified about 100 patients that they may have been exposed to blood-borne diseases and recommended that they be tested for Hep C and HIV.

The nurse was fired by JCMC. She had a compact license, so she started working at Raleigh General in West Virginia.

In March of 2022, that hospital discovered dilaudid vials had been tampered with and reported Brewster to the West Virginia BON. West Virginia suspended her license on 3/22/2022.

The Tennessee Department of Health filed the professional disciplinary case against Brewster with the Board of Nursing on March 31. She is scheduled to appear Aug. 24 at a board hearing and risks losing her nursing license.

If the TN BON had acted, they could have protected patients in WV. They did not act until after West Virginia suspended her license.

https://khn.org/news/article/travel-nurse-opioid-tampering-investigation-jacqueline-brewster/