Download URMC Safety Orientation 2016 - Upson Regional Medical Center

URMC Safety Orientation
2016
Mission of URMC
Upson Regional Medical Center is
committed to providing quality
health care services to all patients
based on the health needs of our
population
Mission
Our goal is to be the employer of
choice for healthcare workers, by
creating a culture where employees
feel valued and are inspired to be
advocates for patients.
Values
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Constancy of Purpose
Integrity & Honesty
Quality Care & Professionalism
Respect & Team Work
Customer Service
Patient Safety
Emergency Code Reporting
Dial Extension 1000 to
Report all Emergencies
and Codes!!
Handouts
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URMC Standards of Behavior
AIDET
Sample Patient Satisfaction Survey
Code Red Procedure
Fire
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Code Red Announcement
 Made over paging system stating general location of
fire
Reporting to Location of Fire
 An available employee from each unit reports &
brings fire extinguisher
 All additional employees report to their work area
Use RACE and PASS
Determination of patients receiving oxygen in clinical
areas
“Code Red, ALL CLEAR”

Do not resume routine function until an “all clear” is
announced
R.A.C.E

Rescue

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Alarm

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Pull alarm and dial extension 1000 to
report fire/location
Contain

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Rescue individuals from immediate
fire/smoke area
Close door to area to contain
fire/smoke
Extinguish

Extinguish the fire if it is safe to do
so
P.A.S.S.
Pull Aim Squeeze Spray
Fire Hazards
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Smoking
 Observe and enforce “No Smoking”
Blockage of Exit Ways
 Keep exit ways clear
Electrical Hazards
 Report any frayed, broken or overheated
cords/electrical equipment
Fire Doors
 Keep all fire doors closed/Do not wedge
or prop open
Hyperbaric Chamber
 Increased risk of flammability
Evacuation
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Hospital designed in a unit concept
to contain fire and smoke
Types of evacuation
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Horizontal=moving laterally
Vertical=moving down one or more
floors
Building=moving out of building
Never evacuate upward; always go
laterally, down, and then out
Refer to charts on each unit for
evacuation procedure
Tobacco Free Campus Policy

No smoking on URMC Premises.
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Includes any indoor or outdoor space
owned, leased or operated by URMC.
Includes parking lots & driveways
Includes vehicles on URMC property
No tobacco applies to all employees,
volunteers, visitors, patients,
physicians, vendors, contracted
employees, contractors, etc.

Tobacco products includes cigarettes, cigars,
pipes, smokeless tobacco, chew, snuff, dip,
electronic cigarettes and any other similar
product
Tobacco-Free Campus Policy


If a student has an odor of smoke,
this is considered violation of policy
and can result in immediate
dismissal
URMC offers a tobacco cessation
program. Call 706-647-8111 (ext.
1149) to register
RAPID RESPONSE TEAM

Purpose:
To provide guidelines for clinical
staff to obtain medical assistance
when a patient exhibits acute
changes in their condition
warranting urgent medical
attention.
Early Warning Signs/Criteria
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Staff member is worried about the patient,
“patient just doesn’t look right”
Acute change in Heart Rate <50 or >120
Acute change in SBP <90 mmHg
Acute change in respiratory rate ≤8 or >28 per
min
Acute change in O2 Sat. <90%, despite O2
Acute change in level of consciousness
Acute change in urinary OP to <100 ml in 4 hrs.,
or <200ml in 8 hrs, if not a renal failure patient
Sudden onset of Chest Pain, if not on Chest Pain
Protocol
New, repeated, or prolonged seizures
Acute uncontrollable Bleeding
RAPID RESPONSE TEAM
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Call the Rapid Response Team (RRT)
when patients meet any of the Early
Warning Signs/Criteria
If there is evidence of Early Warning
Signs, activate the RRT by dialing
extension 1000 and ask the operator to
page the Rapid Response Team to
______ (location)
RN with current ACLS/Critical Care
Experience and Respiratory Therapist
respond
Code Blue – Cardiac Arrest

What is it?
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What Should You Do?
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Cardiac Arrest
Call extension 1000 to report the code and the exact
location.
If available in your area the Code Blue button should
be activated.
If trained to do so, initiate Basic Life Support (CPR)
Who Will Respond?

All physicians in-house at the time, the Emergency
Department (ED) physician on duty, nurses from ICU &
SCU, a nurse from ED that will bring the Rapid
Sequence Intubation (RSI) box, the primary care
giver, Respiratory Therapy, EKG technician,
phlebotomist, any EMT's, and the Director or House
Administrator.
CODE BLUE PALS
Pediatric Cardiac Arrest—age 8 or less

What should you do?
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Follow reporting procedure for Code Blue
When reporting, Say it twice to the operator.
Example: “Code Blue PALS, ground floor,
cafeteria; Code Blue PALS, ground floor
cafeteria”.
Who will respond?
In addition to the routine responders to a Code Blue,
A Pediatric nurse will bring the Pediatric Floor crash
cart to the area where the Code Blue PALS was
called.
Code Blue Outside – Collapsed victim
found outside on the hospital grounds
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What should you do?
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Follow Code Blue Reporting Procedure
State twice to the operator: “Code Blue Outside",
giving exact location.
If you do not have a cell phone, go immediately
to the closest phone to report code. If trained in
BLS, immediately return to the unresponsive
person and initiate BLS.
Code Blue Outside – Collapsed victim
found outside on the hospital grounds
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Who will respond?
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Assigned ED Nurse & URMC Code team members will
respond to the announced Code Blue Outside or
Wellness location.
A Security staff member will obtain the AED,
resuscitation bag, and Code Blue Outside Box from the
ED and transport the ED nurse or assigned Shift
Supervisor to the scene.
Although EMS will be called in an Outside Code Blue it
is at the discretion of the code leader how to transport
the patient.
Note: The hospital has AEDs (Automated External
Defibrillator) for outside use on the hospital's
premises and for use prior to arrival of EMS.

Locations include the Cafeteria, Emergency
Department and Wellness Center
Code Blue in ED—Cardiac Arrest in the
ED
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What is it?
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Patient is in cardiac arrest in ED
Who will respond?
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Phlebotomy, Respiratory, Radiology
(portable), Cardiology (EKG), and
House Admin.
Code Stroke—Patient presents with stroke
symptoms
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Called by the ER Physician or may
be called on an inpatient unit after
Rapid Response Activation
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Pharmacist, Phlebotomist, Respiratory
Therapist, Radiology, EKG Tech, House
Admin., and Stroke Coordinator
respond
CT is prepared to receive patient
If outside of ED, the ED nurse will
respond with TeleNeurology equipment
and medication box
Code Trauma—patient presents with
severe multisystem traumatic injuries
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Phlebotomist, Respiratory Therapy,
Radiology Tech, EKG tech and
House Administrator respond
Code Triage - Internal or external event that
disrupts normal operation or services.
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Large influx of patients (i.e. community disaster)
Event that disrupts normal operation of services (i.e.
building damage from weather-related event)
What should you do?
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Staff at work will report to their work area. Consult with
preceptor or instructor for specific student instructions.
Inpatient care areas, determine the number of patients that
could be sent home.
Prepare to receive patients.
Wear ID badge at all times
Code Tornado WATCH—Conditions
exist for severe thunder storm or tornado
What should you do?
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Report to assigned work area
Close windows and blinds
Remove objects from window sills (books, plants, etc.)
Clear hallways of obstructions
Keep patients & visitors away from windows
Inform patients & visitors of situation
*When safe, an "all clear" will be announced which places
hospital back into normal operation.
Code Tornado WARNING –
A Tornado has been sighted
What should you do?
 Keep patients in their rooms. (Possible Exception: For ICU
and Women’s Services refer to their individual plans.)
 Place patient’s shoes on the patient if possible.
 Move patient’s beds as near to the inner wall (away
from window) as possible.
 Family should also stay in room.
 Close all doors to the patient’s room.
 Limit use of telephones to emergency situations only.
 Remain calm and reassure patients and visitors.
 Prepare to initiate “Code Triage” if necessary.
 Prepare to evacuate if necessary
 *Note: When safe, an "all clear" will be announced which
places the hospital back into normal operations.
Hazardous Materials
SDS
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Safety Data Sheets (SDS)
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Provides proper procedures and
handling for working with a particular
substance
SDS located in each department
CODE ORANGE A hazardous material exposure that has happened in the facility or
outside of the facility.
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A hazardous material exposure that
has happened in the facility or
outside of the facility.
What should you do?
Stay away from the hazardous material or
contaminated person.
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Do NOT go to the Emergency Dept. unless you
are contaminated.
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Direct any guest who arrives and claims
exposure to go outside the building.
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Call Extension 1000 to report the Code Orange.
Who will respond?
Decontamination will take place outside of the
building by the Decontamination Team.
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CODE PINK—Infant or Child Abduction
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What should you do?
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Inform the operator of a "CODE PINK" and give the
age of the patient and the location of the occurrence.
Example: "Code Pink, 5, Pediatrics"
All personnel will be alert to any unusual events or
activity of employees, patients, visitors, or other
internal and external customers.
Flow of traffic out of the hospital and parking lots will
be stopped by designated staff.
Law enforcement is notified.
Note: Internal security systems are used to prevent
infant/child abduction.
CODE MANPOWER –
Patient or visitor has become uncontrollable or violent
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What should you do?
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Notify Operator and give exact location
Who will respond?
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A designated nurse from each unit and all male
employees will respond to the Code Manpower.
The House Administrator or Department
Supervisor will assist with traffic control and send
unnecessary staff back to their departments.
The security officer, in collaboration with the
charge nurse or department manager should
decide whether to call 911 depending on the
extent of the crisis.
Code “B”—Bomb Threat
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What should you do?
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Stay calm. Listen.
Indicate to a co-worker what is occurring. They will
alert the switchboard operator at extension 1000 to
notify the police and Administration.
Try to keep the caller talking. Record date, exact time
and as much of the conversation as you can. Note any
information displayed on the phone.
Listen closely to the caller's voice. Try to determine
and record as much information about the caller and
bomb information as possible.
Who should respond?
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Security, Administration and Law Enforcement
Code Silver –Individual has a weapon
What should you do?
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If you encounter a person with a weapon or if a
hostage situation should occur:
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If you are on the floor of the incident:
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Dial extension 1000 to report code and provide location,
number of perpetrators, victims, and or hostages, and
type of weapon involved.
Remove all patients and personnel from public view.
Locked doors are safest. Safe zones include stairwells and
badge access rooms.
Clear hallway of all people if possible and seek shelter.
Remain out of public view until "All Clear" is called.
All other facility personnel:
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Do NOT go to the area specified in the Code Silver.
Security, Law Enforcement and Administration will
manage the incident.
Door Lock System
Badge Access
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Protects all from unauthorized access and ensures
a safe/secure environment
Highly sensitive areas utilize control access doors
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Emergency Dept
ICU
Labor and Delivery
Medical Records
Nursery
Pharmacy
Some areas, including external doors, lock at a
designated time
If doors are forced open, an alarm will sound
Confidentiality
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Must protect protected health information by law
Signature of Confidentiality Agreement
Violations
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Accessing information not within your scope of
responsibility
Misusing, disclosing, or altering patient info
Disclosing passwords
Leaving a securing application (computer)
unattended
Attempting to access a secured application without
authorization
Violations may constitute corrective action and
termination from clinical rotation
Code Assist –
Assistance is needed to lift or move a patient or visitor

What should you do?
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Staff can initiate the code by calling the operator
at extension 1000, requesting a “Code Assist”
and giving the specific location.
Who will respond?
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A designated staff member from each unit and all
male employees will respond to the Code Assist.
A mechanical lift will be taken to reported
location.
Fall Prevention
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Observe environment for potentially
unsafe conditions
Ensure traffic areas are clear of
obstacles
Clean up spills immediately
Secure electrical cords and wires
away from walkways
Take ownership of your
environment
Fall Risk
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Fall Risk Assessment is completed on all
patients on admission, upon transfer to
another unit, and with any change in
patient condition (i.e. surgery)
Patients who are at a high risk for falls
can be identified by:
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Yellow snap added to wrist band. (mandatory)
Yellow sign “Call, Don’t Fall” posted on door to
patient’s room (mandatory)
Yellow hospital Gown
Bed alarms are to be used for all high
fall risk patients
Post Fall Huddle after a patient fall
Back Safety
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Back Injuries can be costly to you
and to URMC. Let’s Stay Safe!!
Use proper body mechanics:
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Avoid bending at the waist
Bend your knees
Hug the load
Avoid twisting
Push rather than pull
Use lift equipment
Ask for help!!!
Patient Safety:
Identify Patients Correctly
Use at least two identifiers to identify
patients to make sure each patient gets
the correct medicine and treatment.
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Name and Date of Birth or
Name and Medical Record Number
Make sure that the correct patient gets
the correct blood when administering a
blood transfusion.
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Checked by two staff at pick up in the Blood
Bank and by two nurses at the patient’s
bedside before administration.
Patient Safety:
Improve Staff Communication
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Report critical results to the
right staff person and or
physician on time
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Critical Results must be reported to
the physician within 1 hour and
documented in the medical record.
Patient Safety:
Use Medicines Safely--Labeling
 Label
all medicines that are not
already labeled.
 For
example medicines in syringes,
cups and basins. Do this in the area
where medicines and supplies are
set up.
Patient Safety:
Use Medicines Safely--Anticoagulants
 Take
extra care with patients
who take medicines to thin their
blood. The following are used to
insure safety:
 Heparin
Protocol
 Warfarin Protcol
 Lab value monitoring
Patient Safety:
Use Medicines Safely
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Record and pass along correct
information about a patient’s
medicines.
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Find out what medicines the patient is taking and
compare those medicines to new medicines given
to the patient.
Admission Medication Reconciliation completed
on every patient
Must be completed timely
Patient Safety:
Check Patient Medications
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Make sure the patient knows which
medicines to take when they are at
home.
Tell the patient it is important to
bring their up-to-date list of
medicines every time they visit a
doctor.
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Patients receive a “Patient Friendly”
Discharge Medication Reconciliation
Patient Safety:
Prevent Infection—Hand Hygiene
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Use the hand cleaning guidelines from
the Centers for Disease Control and
Prevention or the World Health
Organization
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Hand hygiene expected
Wash hands when hands visibly dirty or
soiled with body fluids
Used alcohol-based hand rub to
decontaminate hands when not visibly
soiled
Secret Shoppers
When to perform hand hygiene
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Before:
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having contact with patients
putting on gloves
inserting any invasive device
manipulating an invasive device
After:
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having contact with a patient’s skin
having contact with bodily fluids or excretions, nonintact skin, wound dressings, contaminated items
having contact with inanimate objects near a
patient
removing gloves
Patient Safety:
Reduce Infection—MDRO’s

Use evidence-based practices to prevent
infections that are difficult to treat
(MDRO=multi-drug resistant organism)
We screen high risk patients for MRSA
 Medical record is flagged if results are
positive
 Contact isolation used for patients with
history or confirmed MDRO
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Patient Safety:
Reduce Infections—Central Line Infections

Use evidence-based practices to prevent
infection of central lines
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Educate staff, patients and families about central
line-associated infections and importance of
prevention
Use a catheter checklist and standardized protocol for
central venous catheter insertion
Perform hand hygiene prior to catheter
insertion/manipulation
Use a standardized protocol to disinfect catheter hubs
and injection ports before drawing blood from central
lines
Evaluate all central venous catheters and remove
nonessential catheters
Patient Safety:
Prevent Post Operative Infections
URMC Strategies:
 Pre-operative Bath
 Pre-operative surgical site prep
 Special Dressings
 Post-op Orders
 Active monitoring
Patient Safety:
Prevent Cather-Associated UTI’s
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Strict criteria for catheters
Actively track all urinary catheters
and promote removal as soon as
possible
Patient Safety:
Identify Patient Safety Risks
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Find out which patients are most likely
to commit suicide.
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Suicide risk assessment for all newly admitted
patients.
High risk patients and patients that have attempted
suicide are placed in safe rooms with one-on-one
monitoring
Patient Safety:
Preventing Wrong Site, Wrong Procedure, and Wrong
Person Surgery

Conduct a pre-procedure verification
process
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Verify the correct procedure, for the correct
patient, at the correct site
When possible, involve the patient in the
verification process
Identify the items that must be available for the
procedure
Use a standardized list to verify the availability of
items for the procedure. Match items to the
patient.
Patient Safety:
Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery
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Site Marking
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Marked when there is more than one possible
location (i.e. Right or Left Extremity)
Before the procedure is performed
Patient involved, when possible
Marked by the physician who is accountable
and present when procedure is performed
Made at or near the procedure site, visible
after site prep and draping
Patient Safety:
Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery

Time Out
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The procedure is not started until all questions or
concerns are resolved
Conducted immediately before procedure or making
incision
Involves the immediate members of the procedure
team and is documented.
Another time-out is performed before starting each
procedure.
Unexpected Events
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Any situation that is not consistent with
the routine operation of the facility or
routine care of the particular patient
Report the following to URMC Staff:
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Patient Injuries
Patient Falls
Treatment Errors
Medication Errors
Unexpected Patient Outcome
Visitor Incidents
Personal Injury
A Variance Report will be completed
Standard Precautions
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Includes hand hygiene
Includes use of personal protective
equipment before exposure to blood, body
fluids, secretions (except sweat), mucous
membranes or non-intact skin
 Gloves-when hand contamination is
anticipated
 Masks and eye protection-when splashes
may occur
 Gowns-when soiling of clothing may occur
Use regardless of diagnosis
ALL patients, ALL the time
Contact Precautions

Prevents transmission of infectious agents that
are spread by direct or indirect contact with the
patient’s environment
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VRE, C. Difficile, noroviruses, RSV, MRSA
Applies to excessive wound drainage & fecal
incontinence
Private room
Wear gown and gloves for all interactions
Don PPE before entry to room and discard before
exiting room
Use of dedicated equipment or clean between use
Airborne Precautions

Prevent transmission of infectious
agents that remain infectious over
long distances when suspended in
the air
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Rubeola virus (measles)
Varicella virus (chicken pox)
Mycobacterium tuberculosis
SARS
Patients places in isolation
Wear mask or respirator (depending
on illness)
Do not enter room if you have not
been fit tested for a respirator
Droplet Precautions

Prevent transmission of pathogens spread
through close respiratory or mucous
membrane contact with respiratory
secretions

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B. pertussis, influenza virus, adenovirus,
rhinovirus, N. meningitides, group A
streptococcus
Private room
Wear a mask when in close contact with
patient
Patient should wear mask if transported
outside of room and follow Respiratory
Hygiene/Cough Etiquette
Medical Equipment
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Equipment used to diagnose, care, treat
or monitor patients
Inspection, testing, maintenance to
minimize clinical and physical risks
Remove and report failed/broken
equipment to staff

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A work order for repair will be completed by
URMC staff
Safe Medical Device Act of 1990 requires
the report of death or serious injury
Orientation is required prior to using
equipment
MRI Safety
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Magnetic Resonance Imaging (MRI)
uses powerful magnetic field, radio
waves and a computer to produce
pictures
“MRI Checklist” completed and
reviewed on every patient prior to
receiving MRI
Iron or other magnetic objects must
not be brought into the neighborhood
of the magnet
MRI is on at all times!!!
No one will be allowed to enter MRI
room without permission of MRI
technologist
Utility Systems

For each type of utility failure, URMC
maintains a Contingency Plan that maps
out:

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What to expect
Whom to contact
Employee responsibilities
Electrical

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During electrical failure utilize red
receptacles/receptacles with red dots
Battery operated flashlights located in each
department
ID Badges


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Wear at all times for security
purposes.
Your badge will only allow access to
allowed departments/locations
Turn your badge in to Human
Resources or forward to Education
Director at the end of clinical
rotation.
Dress Code

As a representative of URMC, it is
appropriate that each staff member
present a neat and well-groomed
appearance in accordance with the
highest standards intended to
insure that the Medical Center
continues its excellent reputation
for rendering quality health care
services.
Dress Code
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School issued scrubs or uniform
acceptable
Clean, unwrinkled, modest clothing
Wear badge @ eye-level
Tattoos covered at all times
Shoes: clean, no toeless shoes or shoes
with holes in top
No chewing gum in patient care areas
Dress Code
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No more than one ring per hand
(exception: wedding set)
Necklaces no longer than18 inches;
simple chain with small pendant allowed
No more than two earrings per ear;
small; no dangling earrings
No other visible piercings
Dress Code
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Hair neat and clean; must be worn so as
it will not interfere with patient care
Facial hair neat and trimmed
Nails short (1/4 “), clean, manicured
No nail polish or artificial nails
May not wear fragrance in patient care
areas
Makeup conservative
Parking

May park lower fenced-in parking
lot (# 4 )
Thank You For
Choosing
URMC!
If you have questions or need
assistance, contact the
Education Dept. @ ext. 1476
Student Safety Post-Test
Student Safety Post-Test
Minimum Passing Score=85
1. Dial extension __________ to report all emergencies and codes to the switchboard operator.
a. 100
b. 1000
c. 0
d. 1234
2. The “R” of the acronym RACE stands for:
a. Rush
b.Respond
c. Rescue
d.Rapid
3. It is acceptable for a student to smoke while on URMC campus.
a. True
b. False
4. You are preparing to enter the elevator and hear a Code Red announced over the intercom, you
know that this means:
a. There is a threat of a fire and you should enter the elevator.
b. There is a threat of a fire and you should take the stairs.
c. There is a threat of a bomb and you should enter the elevator.
d. There is a threat of a bomb and you should take the stairs.
5. You enter a patient’s room and observe that the patient is not breathing. You press the code
button and dial extension 1000 to report a Code ________ and the patient’s room number.
a. Blue
b. Black
c. Orange
d. Pink
6. What does a Code Tornado Warning indicate?
a. Electricity outage
b. Tornado sighting in the immediate area
c. Fire within the building
d. Staff member needs assistance with an aggressive patient
7. You are making rounds on the Postpartum Unit when a mother reports to you that her child has
been taken by someone other than URMC staff. Which code would be implemented?
a. Operation Rescue
b. Code Triage
c. Code Pink
d. Code Blue PALS
Student Safety Post-Test
Filing Number: ADM.EDUC.07.F002 Original or Revised Date: 12/15/2015
Page 1 of 3
Student Safety Post-Test
8. Emergency, ICU, Labor and Delivery, and Nursery departments have door lock systems
requiring badge access.
a. True
b. False
9. Which team would be called in the event a patient’s condition deteriorates?
a. Code Blue Team
b. Rapid Response Team
c. The Raiders
d. The Hospitalist
10. What should occur immediately prior to any operative or bedside procedure to ensure patient
safety?
a. A time out
b. A black out
c. Patient consent
d. Nothing necessary
11. As long as gloves are worn during patient or surface contact, it is not necessary to perform hand
hygiene.
a. True
b. False
12. When hands are visibly soiled, using two pumps of alcohol hand rub is a safe practice for hand
hygiene.
a. True
b. False
13. Contact precautions include:
a. Private Patient Room
b. Wearing gown and gloves for all interactions in the patient’s room
c. Donning PPE after entering the patient’s room
d. A and B only
14. It is necessary to wear a mask for close contact with a patient who has been diagnosed with
influenza.
a. True
b. False
15. A patient is suspected of having Tuberculosis, which precautions are necessary?
a. Airborne isolation room
b. Wear a fit-tested N-95 or higher level disposable respirator and should be
donned prior to entry and removed after exiting the room.
c. Gloves, gown, goggles or face shield if substantial spraying of respiratory fluids anticipated
d. All of the above
Student Safety Post-Test
Filing Number: ADM.EDUC.07.F002 Original or Revised Date: 12/15/2015
Page 2 of 3
Student Safety Post-Test
16. Under what circumstances would Code Triage be called at URMC?
a. An internal or external disaster
b. A patient stops breathing or becomes pulse less
c. An infant/child abduction
d. A patient/visitor becomes aggressive or violent
17. You have a question about handling or working with a particular substance. Which onsite
reference would you seek for more information about the proper procedures?
a. A PDA
b. The preceptor
c. A medical textbook
d. The safety data sheet (SDS)
18. What is one way that fall risk is communicated as part of the fall reduction program at
URMC?
a. A blue bandana
b. A yellow snap on the patient’s wristband
c. A Code Pink
d. A Code Orange
19. It is acceptable to copy the patient’s chart and use patient records outside of URMC for
research or school purposes.
a. True
b. False
20. As a student at URMC, I understand that all patient assessments, treatments, and procedures
must be performed under the direct observation of my preceptor.
a. True
b. False
Student Safety Post-Test
Filing Number: ADM.EDUC.07.F002 Original or Revised Date: 12/15/2015
Page 3 of 3
HIPAA Educational Session
This Session Covers:



HIPAA Privacy Rule
HIPAA Security Rule
Breach Notification Rule
Our HIPAA Officers:
HIPAA Privacy Officer
Suzanne Streetman
Director of Risk Management
Ext. 1240
[email protected]

Call the Privacy Officer w ith
questions about privacy of
oral, paper or electronic
patient inform ation and to
report breaches.
HIPAA Security Officer
Doug Thompson
Chief Information Officer
Ext. 1107
[email protected]

Call the Security Officer w ith
questions about security of
electronic patient inform ation
and protections of our
com puter system s.
“Protected Health Information”
(“PHI”) – Key Term
“PHI” is oral, w ritten or electronic patient
health information relating to a person’s present,
past or future condition, treatment or payment.
Examples:







Medical records
Referral forms
Rx orders
Oral communications about a patient’s health
Test results (x-ray, MRI, CT, labs, etc.)
Billing or claims information
Any info tied to a patient’s health that identifies a patient in any way
NOTE: Patient information and photographic, video and x-ray or other
images are protected health information and should not be disclosed
inappropriately - even if you remove the patient’s name!!
Protected Health Information (“PHI”)
Examples of information that could be PHI when tied to
information about a person’s health, include 




Name
Geographic subdivisions
smaller than state –

Street Address

City

County

Precinct

Zip
Date of birth/death; age
Telephone number
Fax number









Email address
Social Security number
Medical record number
Credit card number
License number
Vehicle license plates
Fingerprint
Full or partial face or other
identifiable images, even xray
Unique identifying
characteristics
HIPAA Privacy Rule Overview

Requires Protection of Oral, Written & Electronic PHI

Restricts Certain Uses and Disclosures of PHI

Provides Individual Patient’s Rights

Establishes Civil and Criminal Penalties for the Health
System and Individual Violators (employees, physicians,
volunteers, medical students, etc.)
Who must comply?
YOU!!
YOU are responsible
for protecting PHI!!
NOTICE OF PRIVACY PRACTICES
(“NOPP”)
URMC uses a NOPP to notify patients about HIPAA at check-in on the
first visit – including






Our Privacy Obligations
Common Uses and Disclosures of PHI
Patient Rights
How for Patient to File a Privacy Complaint.
URMC must post its current NOPP in the facilities and on its
website in clear and prominent location.
Patients must acknowledge in writing receipt of NOPP.
Uses and Disclosures of PHI
HIPAA Privacy Rule allows uses or
disclosures of PHI for 


Treatment of patients
Payment of patient claims/bills
Health care operations of the Health System and its Medical
Staff
**If not expressly permitted by the HIPAA Privacy
Rule, the use or disclosure is NOT allowed without
written, patient authorization.**
Treatment:
PHI can be used or disclosed
for Treatment
Examples:





Provide health care services
Coordinate health care services
Manage health care services
Consults between providers
Referrals from one provider to
another
**HIPAA should never hinder
patient care!!
Payment:
PHI can be used or
disclosed for Payment
Examples:
 Obtain premiums
 Coordinate benefits
 Bill claims
 Obtain payment for
providing care to a
patient
 Obtain pre-authorization
for services
Health Care Operations:
PHI can be used or
disclosed for Health Care
Operations of the Health
System
Examples:







Audits
Customer service
Training
Quality improvement
Grievance resolution
Provider credentialing (peer review)
General business of the health system
NOTE: Use and disclosure for certain
common marketing or fundraising purposes
may be prohibited. Check with the Privacy
Officer.
Other Permitted Uses &
Disclosures of PHI
CONSULT OUR HIPAA POLICIES OR
HIPAA PRIVACY OFFICER BEFORE
USING OR RELEASING PHI FOR
REASONS OTHER THAN TREATMENT,
PAYMENT OR HEALTHCARE
OPERATIONS!!!
Authorization Form
For uses or disclosures of PHI not expressly allowed by HIPAA, patient
should sign a special Authorization form authorizing the release. For
example,

We may need an authorization to use/disclose patient information
for research, marketing and fundraising purposes.

We often must obtain an authorization for release of psychotherapy
notes, AID/HIV info, mental health info, communicable disease info,
alcohol and drug abuse/rehab info, etc.
Check with the HIPAA Privacy Officer for form and/or more information.
Minimum Necessary Rule
The HIPAA Privacy Rule requires you to make reasonable
efforts to limit your uses and disclosures of PHI to the
minimum amount necessary to accomplish the task.

Only use/disclose PHI on a NEED TO KNOW BASIS !!!
The Minimum Necessary Rule does NOT apply to uses and
disclosures 
For treatment,

Made to the individual patient

Made pursuant to a patient written authorization, or

For certain legal and compliance functions
Individual Patient Rights
Under HIPAA, Patients have the:




Right to access, inspect, obtain a copy medical and billing records –
sometimes electronically
Right to request amendment of medical records
Right to an accounting of disclosures of PHI made outside our Health
System and Medical Staff
Right to request restrictions on use/disclosures of PHI

NOTE: Health System may be required to comply with an
individual’s request not to disclose PHI to the patient’s
health insurance company when the individual pays for
health care service out of pocket and in full. See policies.
Individual Patient Rights (cont.)
Under HIPAA, Patients have the:




Right to receive confidential communications

Hospital must accommodate reasonable requests by individuals to
receive PHI communications by alternative means or at alternative
locations.
Right to file complaints about uses/disclosures of PHI
Right to receive written Breach Notification that explains what happened
and how they can protect themselves, etc.
Right to opt out of receiving marketing and fundraising correspondence
SEE OUR POLICIES ON EACH OF THESE PRIOR TO RELEASE OR
AGREEMENT!! NOTIFY THE HIPAA PRIVACY OFFICER IF A
PATIENT WISHES TO ACT ON ONE OF THESE RIGHTS!!
Sale of PHI or Use/Disclosure of PHI
for Personal Gain …



IS PROHIBITTED!!!!!!
IS ILLEGAL !!!!!!
SHOULD NOT BE DONE!!!!!!
Examples:

Selling or using a patient list to promote a product

Removing patient lists when you leave the
hospital / medical office practice

Using the hospital patient lists to promote your or
someone else’s personally owned business.
There are some narrow exceptions. Ask
your HIPAA Privacy Officer.
HIPAA
Security Rule



HIPAA Security Rule protects
electronic PHI (“ePHI”)
HIPAA Security Rule requires
us to protect the integrity,
confidentiality and availability
of ePHI.
URMC has conducted a risk
analysis and has
implemented administrative,
physical and technical
safeguards and an audit
system to protect ePHI.
Security Rule: Safeguards ePHI
URMC has put Administrative Safeguards in place to
protect ePHI, such as:




Risk analysis, assessments
and management
processes
Audits of our computer
systems for inappropriate
uses/disclosures
Workforce access controls
Business associate
contracts with our outside
vendors



Anti-Virus software
Access and password
management and
termination (unique
passwords, etc.)
Contingency plans




Back-up Data
Disaster Recovery Plan
Emergency operation
Testing
Security Rule: Safeguards ePHI
URMC has put Physical Safeguards in place to protect
ePHI, such as:



Facility controls
 Locks on doors
 Visitor limitations
Disaster and emergency
recovery of PHI
Workstation use and
security procedures


Computer disposal and
reuse processes to clean
PHI
Back-up data and storage
processes.
Security Rule: Safeguards ePHI
URMC has put Technical Safeguards in place to protect
ePHI, such as:

Access controls
 Unique passwords
 Auto logoff
 Authentication of user
 Emergency access
procedures

Transmission security
 Integrity controls
 Encryption
Security Safeguards



Our Information Services (IS) uses anti-virus
software and Internet firewalls to protect our network
and computer workstations from malicious software
(malware), viruses, trojans, worms, etc. that could
harm our information systems.
IS controls software updates and patches.
If your computer “freezes,” windows open by
themselves, data is missing, or you experience slow
network performance, you should contact IS
Technical Support at extension 1119 for assistance.
Unique Passwords


Your user name and password is
specific to you. Do not share!!
Safeguard it at all times – if you
think your password has been
compromised, you should
contact Information Systems
Technical Support immediately at
1119.
Encryption



Do not send PHI through email if another
option is available.
You are required to encrypt any outgoing
emails that contain PHI.
Encryption puts the email into an unreadable
code to ensure that unauthorized people
cannot read the email and use the PHI to steal
someone’s identity or cause them harm.
Encryption


Please call ext 1119 for instructions on how to
encrypt outgoing emails.
NEVER send PHI in a Text Message. Texting
PHI is a direct violation of HIPAA Security. Text
messages are not password protected, plus the
receiving device may not be password
protected and encrypted.
Audits
The IS Department audits our computer
systems for inappropriate uses and disclosures
of PHI.
 Therefore, you should be careful of your
actions when using our systems.
 You should never send PHI
to your personal or private email
address, even if you encrypt it as
you send it out.

HIPAA Security Rule


See Additional Rules for Protecting PHI at the end of this
slide presentation for practical tips on protecting ePHI.
Contact the Security Officer with questions and review
the Health System’s full HIPAA Security Policy Manual
available in Policy Manager.
Be Careful When Using Social
Media in the Health Care Industry



Examples of common social media: Facebook, Twitter,
YouTube, texting, emailing, etc.
Because you work in the health industry, you are
constantly exposed to confidential, highly sensitive
patient and business information.
DO NOT use or disclose patient or confidential business
information on social media sites.

Why?? Because federal and state laws prohibit
disclosure of this information . . . and because your
patients and job depend on it!
What Is Social Media?
Use of Social Networks 

Use of Facebook, Twitter, YouTube, blogging and similar social or
business networking applications while at work “on the clock” is
prohibited.

Remember if you access social media sites from a personallyowned device, you should do so only during breaks or lunch –
and then do so responsibly. Social media networking is
distracting and could lead to patient care and privacy issues.

If you identify your employer on your personal social media
page, you should make it clear that your views are your
personal views and are not those of this Health System.
At any time, on any form of social media:

Never post Health System trade secret, proprietary or
confidential business info!!

Never post patient information (“PHI”), even if you remove the
name!!

Examples of prohibited posts:

I had a terrible day. 22 yr old patient died in ED. 

I love my new job: I got to treat a burn victim today!!
Use of Social Networks (cont.)



Never photograph or video patients with cameras, cellular
phones, smart phones or similar devices and never post
photos/x-rays, etc. on networking sites – even if the name of
the patient is deleted.

Never email PHI outside of this Health System to a private
home address or to an unauthorized person/company.
NOTE: Health System social media policies are not meant to
prohibit employee NLRA Section 7 protected activities.
Violations of social media restrictions may result in disciplinary
actions – particularly if it results in a privacy violation or is deemed
to have interfered with your job performance.
Potential HIPAA Penalties

Violating patient privacy under HIPAA has
criminal penalties as well as civil. These
include:



Up to $50,000 fine and up to one year in jail for
knowingly obtaining or disclosing PHI in violation of
HIPAA
Up to $100,000 fine and up to 5 years in jail for doing
the above under false pretenses
Up to $250,000 fine and up to 10 years in jail for
doing the above with the intent to profit or do harm
with the information
Potential HIPAA Penalties
Other penalties can include Loss
of Job


NOTE OF CAUTION: The HIPAA
Security Rule requires us to audit
our computer systems for HIPAA
compliance. Our system creates a
snapshot of the records you view,
print, forward and disclose.
We can tell if you are viewing or
sending PHI when you should not.
So, do not do it!!!
Our HIPAA Privacy and Security Rules
Protecting PHI requires an individual and team effort. There are many
good habits you can practice to help protect our patients privacy.
Some of these include:

Read and refer often to our HIPAA Privacy and Security Policies and
Procedures, available in Policy Manager.

If you see PHI lying around, pick it up and make sure that it is delivered to
the appropriate person/place.

Be discrete when talking about PHI in
open areas. Keep your voice down!

Don’t discuss PHI in the cafeteria,
elevators, at home or in public places
(even in religious settings such as during
prayer requests).
Our Rules (Continued)

Help your co-workers comply with HIPAA by bringing noncompliant actions to their attention.

Access and disclose PHI only on a “need to know” and
“minimum necessary” basis.

Always use appropriate fax cover sheets for all out-going
communications containing PHI - warning the recipient that PHI
is enclosed and should be protected.

Check email and fax addresses before hitting “send.”

Log out, secure or lock your computer (if possible) when away
from your screen. Turn screens so that they cannot be viewed
by public/visitors/unauthorized employees.

Avoid leaving clipboards with medical information in places
where it could be looked at, altered, or stolen.
Our Rules (Continued)

DO NOT talk about patient issues with friends,
family, or in public places.

Never share your computer user name or
password with anyone. REMEMBER: Your user
name and password tie any computer activity to
you! We audit for security compliance.

Lock doors or file cabinets that should be locked.

Never take or send PHI (electronic or hardcopy)
outside of the facility unless you have permission
to do so.

Store laptops in trunk of vehicle – not in open
view.
Our Rules (Continued)

Do not save PHI to unencrypted disks or drives.

Do not social network while at work – no Twitter, blogging, Facebook, cell
photos, etc. Do not post PHI on social network sites.

Follow Policies and Procedures for retaining and disposing of PHI. Shred
PHI before throwing into a trash can or dumpster.

Follow Policies and Procedures for reporting concerns about
wrongful uses/disclosures or conduct involving PHI.

Report any suspected breaches of
PHI immediately to the Privacy
Officer.

Protect PHI as if it were your own!!
Report Suspected Wrongful Conduct


URMC’s ability to prevent and detect wrongful conduct in a timely
manner depends, in part, on the eyes and ears of its workforce and
medical staff.
Employees are encouraged to report suspected wrongful conduct or
concerns without fear of retaliation as the result of the report by:




Discussing the concern with a supervisor.
Contacting the HIPAA Privacy Officer or HIPAA Security Officer
Leaving a message on Compliance confidential hotline.
Contacting Compliance Officer directly.
**It is a condition of your employment that you report suspected wrongful conduct as soon as
you become aware of it.
**If we know about a problem, we can correct it before it becomes a bigger problem!!
HIPAA Breach Notification


REPORT all potential Breaches to
the Privacy Officer ASAP!! The
Privacy Officer will determine
whether notice of the Breach must
be given to the patient, media and
federal government.
HIPAA requires the Health System
Privacy Officer to send written
notice to a patient of a Breach of
PHI, in some cases when required
by law.
REACH is an unauthorized use, access or disclosure of
unsecured PHI.
HIPAA Breach Notification
Wrongful or inadvertent uses or disclosures of PHI
could qualify as a Breach and should be reported
to the Privacy Officer.
Examples of Potential Breaches:







A lost or stolen laptop containing PHI
Failing to shred patient records before throwing them away
Giving PHI to an unauthorized person
Leaving medical records open and in plain view
Gossip
Sending PHI to a home yahoo or gmail email account
Reviewing medical records of yourself, friends, family members, significant
others or celebrities (NO snooping!!)
HIPAA Student Post-Test
Name: ___________________________________
Date: _______________
The minimum passing score is an 88.
1. To protect my password, I should: (select EACH answer that is true; this question may have
more than one correct answer)
Answers
□ Write it on a note taped to my computer monitor so that it will be easy to remember.
□ Use a “strong” password that includes letter, numerals, and special characters.
□ Change my password immediately and report this violation if I think my password has been
compromised.
□ All of the above
2. When entering a patient room where a visitor/family member is present,
Answers
□ I should give the patient the opportunity to object my discussing his/her care in front of the
visitor/family.
□ I should ask the patient if it is okay that I talk to him/her in front of the visitor/family.
□ I should not assume a visitor is a family member involved in the patient’s care just because the
visitor is of the same race as the patient or because the visitor appears to be very friendly with the
patient.
□ All of the above.
3. There are no limits on uses and disclosures of protected health information (PHI).
Answers
□ True
□ False
4. Choose the item(s) that are protected health information (PHI) and that should be protected from
inappropriate uses or disclosures:
Answers
□ Information about a patient’s past health care that could identify the patient
□ Information about a patient’s present health care that could identify the patient
□ Information about a patient’s future health care that could identify the patient
□ All of the above
5. Workforce members should not engage in social networking (e.g. Facebook, Twitter, testing,
YouTube, etc.) while at work and should not ever discuss or post patient information/images or xrays on such sites even if the patient name has been removed.
Answers
□ True
□ False
HIPAA Student Post-Test
Filing Number Original or Revised Date
Page 1 of 3
HIPAA Student Post-Test
6. Individuals have a right to:
Answers
□ Request an account of certain disclosures of PHI.
□ Ask that a provider not disclose treatment information to a health plan if the patient has paid out of
pocket and in full for the service.
□ Request a copy of the individual’s medical records in electronic format.
□ Request confidential communications and/or their name not be listed in the hospital or nursing
home directory.
□ All of the above
7. It is acceptable to share a patient’s medical record with:
Answers
□ Clinicians involved in the patient’s treatment
□ People with a legal right to review the record
□ Agencies (such as a state surveyor, DNV, CMS) looking into the quality of care at the facility
□ All of the above
8. I am required to report any suspected breaches or security incidents to the HIPAA Privacy Officer.
Answers
□ True
□ False
9. Only the health care entity can be penalized for non-compliance with HIPAA. Individual employees
cannot be held accountable.
Answers
□ True
□ False
10. Which of the following are examples of controls that protect the security of our computer systems?
Answers
□ Internet firewalls
□ Anti-virus software
□ Installation of software updates and patches
□ All of the above
11. Which of the following are examples of protected health information (PHI)?
Answers
□ Diagnostic test results (lab, ultrasound, etc.)
□ The patient’s date of birth
□ The patient’s name
□ Electronic medical records
□ Paper medical records
□ Health insurance claim form
□ All of the above
HIPAA Student Post-Test
Filing Number Original or Revised Date
Page 2 of 3
HIPAA Student Post-Test
12. It is acceptable to send PHI to my home email (e.g., Yahoo, Gmail, etc.) so that I can work on
work-related projects at home as long as my supervisor has given approval.
Answers
□ True
□ False
13. Which of the following could qualify as a breach of PHI?
Answers
□ Lost or stolen laptop with patient billing or medical records
□ Posting PHI to Facebook about my day at work
□ Throwing out patient files in the trash/dumpster without appropriately shredding
□ Snooping in my own or my significant other’s medical record
□ Misdirected emails or faxes or sending PHI to my home email address
□ All of the above
14. It is acceptable for me to give my cousin a copy of a patient list so that he can send flyers notifying
the patients that he is opening a new business in town.
Answers
□ True. This is a great way for my cousin to grow his new business.
□ False. Sale or inappropriate use or disclosure of PHI is illegal and could result in civil and criminal
penalties (including jail time).
15. What statements are true about HIPAA?
Answers
□ It is federal law.
□ It affects all in the health care industry.
□ It protects the privacy and security of a patient’s health information.
□ It sets standards for electronic and physical security of a patient’s health information.
□ All of the above.
16. Dr. Steve Urkel is on call and in charge of Ms. Statis Ulcer’s care. During the shift, the patient’s
temperature becomes high and she has abnormal lab results. It is acceptable for the nurse to text Dr.
Urkel to report this.
Answers
□ True
□ False
HIPAA Student Post-Test
Filing Number Original or Revised Date
Page 3 of 3
Confidentiality and Non-Disclosure Agreement
Organizational information that may include, but is not limited to, financial, patient identifiable, employee
identifiable, intellectual property, financially non-public, contractual, of a competitive advantage nature, and
from any source or in any form (i.e. paper, magnetic or optical media, conversations, film, etc.), may be
considered confidential. (Information’s confidentiality and integrity are to be preserved and its availability
maintained). The value and sensitivity of information is protected by law and by the strict policies of Upson
Regional Medical Center. The intent of these laws and policies is to assure that confidential information will
remain confidential through its use, only as a necessity to accomplish the organization’s mission.
As a condition to receiving a computer sign-on code and allowed access to a system, and/or being granted
authorization to access any form of confidential information identified above,
I, the undersigned, agree to comply with the following terms and conditions:
1. My Sign-On Code is equivalent to my LEGAL SIGNATURE and I will not disclose this code to anyone or
allow anyone to access the system using my Sign-On Code.
2. I am responsible and accountable for all entries made and all retrievals accessed under my Sign-On Code,
even if such action was made by me or by another due to my intentional or negligent act or omission. Any data
available to me will be treated as confidential information.
3. I will not attempt to learn or use another’s Sign-On Code.
4. I will not access any on-line computer system using a Sign-On Code other than my own.
5. I will not access or request any information I have no responsibilities for. In addition, I will not access any
other confidential information, including personnel, billing or private information.
6. If I have reason to believe that the confidentiality of my User Sign-On Code/password has been
compromised, I will immediately change my password and notify the Security Officer.
7. I will not disclose any confidential information unless required to do so in the official capacity of my
employment or contract. I also understand that I have no right or ownership interest in any confidential
information.
8. I will not leave a secured computer application unattended while signed on.
9. I will comply with all policies and procedures and other rules relating to confidentiality of information and
sign-on codes.
10. I understand that my use of the system will be periodically monitored to ensure compliance with this
agreement.
11. I agree not to use the information in any way detrimental to the organization and will keep all such
information confidential.
12. I will not disclose protected health information or other information that is considered proprietary, sensitive,
or confidential unless there is a need to know basis.
13. I will limit distribution of confidential information to only parties with a legitimate need in performance of
the organization s mission.
14. I agree that disclosure of confidential information is prohibited indefinitely, even after termination of
employment or business relationship, unless specifically waived in writing by the authorized party.
15. This agreement shall survive the termination, expiration, or cancellation of this agreement.
16. I understand that if I access information intentionally outside of the scope of my work that I may be held
responsible for penalties and fines associated with my actions.
Print Name: ____________________________Role: ______________________________
SIGNATURE:
_______Date and Time: ___________________
Confidentiality and Non-Disclosure Agreement
HIPAA.ADM.509.F001 Revised: 07/02/2015
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Cultural Diversity
Diversity in the Workplace
Objectives:
• Raise level of awareness about
importance of sensitivity to diversity of
health care workers.
• Provide language around topic of diversity.
• Learn tools to work effectively with a
diverse customer base.
What Exactly Is “DIVERSITY”?
• Diversity refers to all the ways that
individuals are unique and differ from one
another.
• Broken down into PRIMARY and
SECONDARY characteristics.
Examples of Diversity
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Age
Race
Marital Status
Education
Profession
Religion
Gender
Likes/Dislikes
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Language
Lifestyle
Life Experiences
Geographic Location
Eye Color
Sexual Orientation
Disability
Economic Status
Primary Characteristics:
Qualities We Are Born With
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Gender
Eye Color
Hair Color
Race
Birth Defects
Secondary Characteristics:
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Religion
Educational Level
Parental Status
Geographic Location
Socioeconomic Status
What Exactly Is “Culture”?
• Patterns of Daily Living by a Group of
People Learned Consciously or
Unconsciously
Examples of Culture
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Language
Practices
Customs
Food
Clothing
Religion
Superstitions
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Architecture
Holiday Celebrations
Family Unit
Dating Rituals
Art
Governing
Music
Barriers to Accepting Others
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Perceptions
Bias
Prejudice
Stereotypes
PERCEPTION
• Thought resulting from a feeling.
• Based on opinions, likes, dislikes,
attitudes, beliefs, values and
rationalizations
BIAS
• An inclination - either for or against an
individual or group that interferes with
impartial judgment.
PREJUDICE
• Pre-judging a person or group without
sufficient knowledge.
• Frequently based on stereotypes.
STEREOTYPE
• An oversimplified generalization or mental
picture about a person or group without
regard for individual difference.
Components of Communication
• Tone of Voice (38%)
• Body Language (55%)
• Spoken Language (7%)
Foundations of Communication
• Showing Respect
• Demonstrating Empathy
• Being genuine
RESPECT
• Accepting people without necessarily
agreeing with them.
• Genuinely valuing and supporting without
patronizing.
EMPATHY
• Accurately understanding people’s
feelings.
• Recognizing an individual’s needs.
• Showing sensitivity to the content, nature
and intent of people’s concerns.
BEING GENUINE
• Being sufficiently aware of self to behave
in ways that are aligned with inner feelings
and thoughts.
• Being aware of own limitations in
interacting with others.
Bridging Diversity
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Learn about other cultures.
Be willing to accommodate.
Be open and flexible.
Challenge perceptions.
Practice active listening.
Avoid judging.
Be patient.
Bridging Diversity (Cont’d)
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Practice effective communication skills.
Look for similarities.
Show respect.
Understand your biases.
Avoid slang.
Embrace differences.
See diversity as a STRENGTH!
Diversity may be the hardest thing for a
society to live with, and perhaps the most
dangerous thing for a society to be
without.”
-William Sloane Coffin, Jr
Safety Orientation Checklist
STUDENT ORIENTATION SCHEDULE
Name: ______________________________________________________________
Address: _____________________________________________________________
City: _________________________ State: ______
Zip: _________________
Phone : _______________________________ Email:___________________________________
Unit/Office/Dept Name: ____________________
Preceptor: _____________________________
Clinical Rotation Beginning & End Date: _______________ through _______________
Role (circle one):
PA Student
RN Student
Physician Student
LPN Student
Other (specify) _______________________________
Please initial each item
_____ 1. Safety Orientation/URMC Emergency Code Review
• Mission, Vision, Values
• URMC Standards of Behavior/AIDET/Patient Satisfaction
• Fire Hazards/No Smoking Policy/Evacuation Procedure
• Safety Data Sheets
• Confidentiality
• Fall Risk/Back Safety
• Patient Safety Practices/Variance Reports
• Standard, Contact, Airborne and Droplet Precautions/Hand Hygiene
• Medical Equipment/MRI Safety/Contingency Plan for Utilities
• ID Badge & Door Locks
• Dress Code
• Parking
_____ 2. Cultural Diversity Handout Received
_____ 3. Confidentiality Agreement and HIPAA Post-Test completed
_____ 4. Windows and Meditech Access Forms Signed (if applicable)
_____ 5. Intranet Resources Reviewed
a) Policy Tech
b) Clinical Links
_____ 6. Pyxis Patient Supplier Access (if applicable)
_____ 7. Preceptor Contact Info/Schedule/Instructions
_____ 8. Obtain Badge from Human Resources
Student Signature: ________________________________________
Instructor Signature: ______________________________________
Safety Orientation Checklist
Filing Number: ADM.EDUC.07.F001
Revised Date: 12/10/15
Date: _________
Date: _________
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