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National Patient Safety Goals
Mac Neal Hospital
2011
National Patient Safety Goals
Purpose
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The purpose of The Joint Commission’s National
Patient Safety Goals (NPSGs) is to promote
specific improvements in patient safety
The Requirements highlight problematic areas in
health care and describe evidence and expertbased solutions to these problems.
The Requirements focus on system-wide
solutions, wherever possible.
2011 National Patient Safety
Goals
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Approved by The Joint Commission’s Board of
Commissioners
The Goals and Requirements are programspecific
Include improvements emanating from the
Standards Improvement Initiative, including:
– New numbering system for sorting in new
electronic manuals
– Minor language changes for consistency
Patient Identification
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Improve the accuracy of patient
identification
Goals
Goal
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Goals
Goal
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Goals Goal
Goals
Goals
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Goal
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Patient Identification
Use at least two patient identifiers (name
& birth date) when providing care,
treatment and services.
 Prior to the start of any surgical or invasive
procedure, individuals involved in the
procedure conduct a final verification
process, such as a time-out, to confirm the
correct patient, procedure and site using
active, not passive, communication
techniques
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Patient Identification
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Eliminate transfusion errors related to
patient misidentification.
Improve Communication
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Get the important test results to the right staff
person.
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For telephone orders or for telephone reporting
of critical test results, the individual giving the
order verifies the complete order or test result by
having the person receiving the information
record and "read-back" the complete order or test
result.
Improve Communication
There is a standardized list of
abbreviations, acronyms, symbols, and
dose designations that are not to be used
throughout the organization.
 The organization measures, assesses and, if
needed, takes action to improve the
timeliness of reporting, and the timeliness
of receipt of critical tests, and critical
results and values by the responsible
licensed caregiver.
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Improve Communication
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The organization implements a
standardized approach to hand-off
communications, including an opportunity
to ask and respond to questions.
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At MacNeal we use SHARER (sketch,
how, aim, rationale, exchange, & review).
Medication Safety
Improve the safety of using medications
 The organization identifies and, at a
minimum, annually reviews a list of lookalike/sound-alike medications used by the
organization and takes action to prevent
errors involving the interchange of these
medications.
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Medication Safety
Label all medications, medication
containers (for example, syringes,
medicine cups, basins), or other solutions
(including water on and off the sterile
field.
 Reduce the likelihood of patient harm
associated with the use of anticoagulation
therapy.
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Health Care Associated Infections
Reduce the risk of health care associated
Infections.
 Comply with current World Health
Organization (WHO) hand hygiene
guidelines or Centers for Disease Control
and Prevention (CDC) hand hygiene
guidelines.
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Health Care Associated Infections
Manage as sentinel events all identified
cases of unanticipated death or major
permanent loss of function related to a
health care associated infection.
 Implement evidence-based practices to
prevent health care associated infections
due to multiple drug-resistant organisms in
acute care hospitals.
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Health Care Associated Infections
Implement best practices or evidencebased guidelines to prevent central lineassociated bloodstream infections.
 Implement best practices for preventing
surgical site infections.
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Reconcile Medications
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Find out what medications the patient is taking.
Make sure that it is OK for the patient to take any
new medication with their current medicines.
Give a list of the patient’s meds to their new care
giver. Give the list to the patient’s primary doctor
before the patient goes home.
Give a list of the patient’s medications to the
patient and their family before they go home.
Explain the list.
Reconcile Medications
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In settings where medications are used
minimally, or prescribed for a short
duration, modified medication
reconciliation processes are performed.
Reduce Falls
Reduce the risk of patient harm resulting
from falls.
 The organization implements a fall
reduction program that includes an
evaluation of the effectiveness of the
program.
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Influenza & Pneumococcal
Disease
Reduce the risk of influenza and
pneumococcal disease in institutionalized
older adults.
 The organization develops and implements
protocols for administration of the flu
vaccine.
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(Joint Commission, 2009)
Influenza & Pneumococcal
Disease
The organization develops and implements
protocols for administration of the
pneumococcus vaccine.
 The organization develops and implements
protocols to identify new cases of
influenza and to manage outbreaks.
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(Joint Commission, 2009)
Surgical Fires
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Reduce the risk of surgical fires.
The organization educates staff, including
licensed independent practitioners who are
involved with surgical procedures and anesthesia
providers, on how to control heat sources, how to
manage fuels while maintaining enough time for
patient preparation, and establish guidelines to
minimize oxygen concentration under drapes.
Patient Involvement
Encourage patients’ active involvement in
their own care as a patient safety strategy
 Identify the ways in which the patient and
his or her family can report concerns about
safety and encourage them to do so.
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Pressure Ulcers
Prevent health care associated pressure
ulcers (decubitus ulcers)
 Assess and periodically reassess each
resident’s risk for developing a pressure
ulcer (decubitus ulcer) and take action to
address any identified risks.
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Risk Assessment
The organization identifies safety risks
inherent in its patient population.
 The organization identifies patients at risk
for suicide.
 The organization identifies risks associated
with home oxygen therapy such as home
fires.
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Changes in Patient Condition
Improve recognition and response to
changes in a patient’s condition.
 The organization selects a suitable method
that enables health care staff members to
directly request additional assistance from
a specially trained individual(s) when the
patient’s condition appears to be
worsening.
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Universal Protocol
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The organization meets the expectations of
the Universal Protocol.
– Conduct a pre-procedure verification process.
– Mark the procedure site.
– A time-out is performed immediately prior to
starting procedures.
Utility Systems
Utility Failure-CODE GREEN
Oxygen/Medical Air/and Suction
 Water
 Electricity
 Waste Removal (Sewage)
 Natural Gas
 Telephones
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Utility Failure-CODE GREEN
Reporting Utility Problems
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If you come across problems or failures of
any utility system
–Report-call security at x 3163
–Security will call Facility Services
–Notify your supervisor
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Facility Services will
–Inspect the situation
–Initiate corrective action
Other Utility Failures
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Contingency plans are in place for utility
failures
...Ask supervisor for details
Power Failure- Main Campus
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Main Campus power disruption
– Emergency generators automatically start
– Emergency power in 10 minutes or less
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Generators
– Provide power to the main campus in emergencies
– For more than 24 hours
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Coverage includes
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Critical medical equipment
Emergency lighting
Designated elevators
Red outlets
Battery power lights
– Provides illumination
– Provides safety for generator turns on emergency power
Power Failure- Main Campus
Connect critical components into RED outlet
(IV’s etc..)
Power Failure – Off-Site Facilities
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Battery powered lights
– Illumination for up to 1 hour
– limited illumination for exiting premises
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Facilities with generators which support a
limited amount of equipment
– Harlem- Ogden bldg
– Mid City Bank bldg
Telephone System Failure
Main Campus
• The red telephones may be the only working
telephones
• Used as a back up system
• Separate phone numbers are attached to each
red telephone
Oxygen/ Medical Air/ Suction Shutoff Valves
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Shut-off valves are located throughout the
hospital in areas where services at off valve used
Adjacent to the shut- off valves is a map
indicating which rooms these valves serve and
the emergency protocol
If you work in an area utilizing these services,
familiarize yourself with this information
Only shut off the service in an emergency
condition, following the approved protocol for
medical gas shutdown
Medical Equipment & Electrical
Safety
Electrical Safety Considerations
If a device has a power cord it must be
safety tested by Facilities Services or
Biomedical Engineering prior to being put
into service
 Patient owned electrical items (radios, hair
dryers, etc..) are not allowed unless the
device is battery operated
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Electrical Safety Considerations
Don’t unplug equipment by pulling on the
power cord; use the head of the plug
 Always check the condition of the plug
before inserting it into the outlet
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Reporting Electrical Hazards
Immediately report any non-static
electrical shocks to your supervisor
 Unsafe equipment should also be reported
immediately to:
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– Biomedical Services ( x3715)
– Biomedical Services after hours pager (3715)
– Facility Services ( x3137)
Safe Medical Device Act
The S.M.D.A. is a federal law designed to
protect you and the patients
 There are two important regulations in this
act that could affect you
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– The Device Tracking Regulation
– The Medical Device Reporting (MDR)
Regulation
Definition of Medical Device
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A Medical Device is:
– Any device used in the treatment,
therapy or diagnosis of patients
Medical Devices Include
Hospital Bed
Wheelchair
Defibrillator
Syringe
• Infusion pumps,
defibrillators, monitors,
implantable devices
• Beds, syringes, IV lines,
wheelchairs
Device Tracking Regulation
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Certain Medical devices are required by
the FDA to be tracked.
– IV pumps
– Implantable devices
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pacemakers
Medical Device Reporting (MDR)
Regulation
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Medical Device Reporting is required
– If a device may have contributed to a patient
or employee’s
Death
 Serious injury
 Serious illness
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General Guidelines
Medical Device Incident Management
Attend to the medical needs of the patient
 Report the incident to the appropriate
person
 Notify Risk Management and/or the AOD
 Complete an occurrence report within 24
hours
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General Guidelines
Medical Device Incident Management
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Remove the device from service
– Contact security at x 3163
– Security will store the item in a secure
location for further investigation
General Guidelines
Medical Device Incident Management
Do not change the settings on the device
 Label the device
 Do not use or discard
 Describe the malfunction
 State how you may be contacted
 If the device is reusable- record
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– Serial numbers
– Identification numbers
General Guidelines
Medical Device Incident Management
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Save all the materials
– Don’t take device apart
– If you must take it apart –save everything
– Save all original packing- if possible
Chemical
and
Hazardous
Material Safety
MSDS for most Chemicals and
Hazardous Materials
Every department is responsible for
keeping corresponding MSDS for all
hazardous chemicals used in their area
 The Emergency Department will have a
master inventory of all MSDS
 The MSDS list is on the intranet, on the
Pulse page.
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Proper Labeling
The chemical should remain the original
container
 The original label must remain on all
chemicals
 If a chemical must be transferred to a
different container, that new container
must be properly labeled
 Additional labels can be obtained by
calling that vendor
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M.S. D. S. Hazard Rating Label
Determination
Red = Flammability
 Blue = Health
 Yellow = Reactivity
 White = Specific Hazard
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Code Orange
This code is used in the event of a large or
extremely hazardous material spill
 If this were to occur in your area
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– Move to a safe location
– Contact your supervisor
– Await further instructions
Biohazard Items
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Biohazard items include and are not
limited to:
– Syringes
– Blood
– Blood and body fluid specimens
PNEUMATIC TUBE SYSTEM FOR TRANSPORT
OF BLOOD PRODUCTS AND SPECIMENS
POLICY
Due to the potential for leakage and/or contamination from certain blood
products and specimens, the Pneumatic Tube System (PTS) will not be used
for transporting the following specified substances:
– 24 hour urine specimens
– spinal fluid
– stool specimens
– surgical specimens
– biopsy specimens
– cytology specimens
 All other specimens not identified above, including blood specimens (i.e.,
tubes of blood) may be transported via the Pneumatic Tube System.
PROCEDURE
 Transporting approved specimens via the PTS.
– All specimens must be placed in an appropriate container prior to
transport.
– Assure that specimen is properly labeled and accompanied by
appropriate requisitions.
– Specimens for which use of the PTS is contraindicated must be hand
carried to the laboratory.
– All specimens must be placed in an appropriate, sealed container.
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(MacNeal Hospital Infection Control Policy and Procedure for the use of the pneumatic tube system for the transport of blood products and specimens , 2006).
PNEUMATIC TUBE SYSTEM FOR TRANSPORT
OF BLOOD PRODUCTS AND SPECIMENS
POLICY
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Blood products:
– Only in the event of a transfusion reaction should all tubing's and
infusates be returned to the blood bank in a zip lock impervious bag. If
the blood product was infused with no transfusion reaction the used bag
and tubing should be placed in the biohazard container.
– When sending a blood product back to the blood bank after a transfusion
reaction, the roller clamp on the infusion set should be moved to a
position immediately adjacent to the connection site of the bag and
tightly closed. This will prevent leakage of residual fluid from the
infusion bag. If the entire tubing does not have to be returned to the
blood bank, the segment of tubing below the roller clamp should be cut
off and discarded.
– The transfusion requisition must be securely attached to the outside of
the bag prior to transport.
– Sterile Processing will decontaminate the zip lock bag and/or the tube in
the event of contamination.
(MacNeal Hospital Infection Control Policy and Procedure for the use of the pneumatic tube system for the transport of blood products and
specimens , 2006).
Transporting Biohazard Specimens
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All specimens are considered BIOHAZARD
– All specimens sent through the tube system must be in
a plastic specimen bag and wrapped in bubble wrap if
breakable
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Hand Carry
– Specimen in plastic specimen bag
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Driving
– Transport specimen in closed protected container in
back of car or trunk
Personal Protective Equipment
Gloves
 Face Mask
 Goggles
 Lab Coat
 Apron
 Respirator Mask
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Hazardous Materials: Receiving,
Transporting, Storage, and Labels
Policy
 The following precautions shall be observed in receiving,
transporting, and storing hazardous drugs.
Receiving
 No special precautions are necessary if cartons or
containers are undamaged. If cartons or containers are
damaged proceed as follows:
 Wear protective apparel (gown, gloves, mask, eye wear)
as described in this policy.
 Open damaged shipping cartons of hazardous drugs in an
isolated area.
 Place broken containers and contaminated materials in
disposal containers as described in this policy.
MacNeal Hospital, POLICY NUMBER: 04-11 revised 1-1-2008)
Hazardous Materials: Receiving,
Transporting, Storage, and Labels
Transporting
 Securely cap or seal hazardous drugs in specially labeled containers
and protect them during transport.
 Do not transport hazardous drugs by any method that could increase
the chance of breakage (e.g., pneumatic tube).
Storage
 Facilities used for storing hazardous drugs should, if possible, be
used for no other drugs. Storage methods shall prevent containers
from falling to the floor, i.e., bins or shelves with barriers at the front.
The Director of Pharmacy, if deemed necessary, shall designate a
special area for the storage of these drugs and shall place warning
label (s) at that area.
Labels for hazardous substances
 Labels for hazardous substances shall indicate that the contents
contain a hazardous drug (and other information that will assure safe
handling and disposal).
(MacNeal Hospital, POLICY NUMBER: 04-11 revised 1-1-2008)
When do I wear Personal
Protective Equipment (PPE) ?
Always wear PPE when working with or
handling Hazardous Materials
 Each department has specific guidelines
for PPE equipment according to the type of
work performed
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Disposal ?
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Chemicals and hazardous waste must be
disposed of according to local regulations
and MSDS guidelines
Code Event & Code Designation
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Code Red
– Fire
Code Blue
– Medical Emergency-Cardiac
Arrest
Code Blue- Pediatrics
– Pediatric Emergency
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Code Yellow
– Trauma Team Activation
Code Pink
– Infant abduction
Code Grey
– Security Assistance
Code Triage –Standby
– Disaster Plan Standby
Code Triage
– Disaster Plan Activation
Code Purple
– Evacuation
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Code Black Watch
– Severe Weather L-1
Code Black Warning
– Severe Weather L-2
Code Orange
– Hazardous Material Rel.
Code Green
– Utility Failure
Code Safe
– Safety Secured
Code Navy
– Level I/ High bed census
– Service lines at capacity
Code Bronze
– Level II/ High bed census
– Emergency Department 1 hour
from bypass (Diversion)
All Clear
– Situation Cleared/ All Clear
Questions ?
Cultural Diversity and Sensitivity
Culturally sensitive care is the right of all
clients. Everyone who represents
MacNeal Health Network (employees,
volunteers, students, contracted staff,
licensed independent practitioners, etc.) is
ethically obligated to the provision of
culturally- sensitive care to all individuals
that enter our health care system.
Cultural Diversity and Sensitivity
Meeting this obligation requires we open
our minds, an honest examination of one’s
own values and beliefs, a willingness to
learn and an awareness that each cultural
and ethnic group has values, beliefs t are
and practices that are specific to the group.
We must always be mindful that each
clients cultural needs must be assessed and
addressed from an individual perspective.
Cultural Diversity and Sensitivity
Various resources to aid your effectiveness
in providing culturally sensitive care are
readily available at MacNeal Health
Network. These resources can be accessed
on the Intranet and within the
administrative policy manual. To access
these resources, inquires can be made to
the members of the management team.
Patients Rights and Responsibilities
Policy:
 MacNeal Hospital recognizes and respects the rights of individuals to
be involved in decisions about their care, treatment, and services and
strives to maintain high standards as we care for our patients with
compassion and skill. MacNeal Hospital believes patient rights
deserve our greatest attention.
 MacNeal Hospital posts notices and provides informational material
supportive of patient rights and patient responsibilities. In addition,
the Hospital makes available to the patient and/or the family or legal
representative the services of an Ethics Consultant, Interpreter
Services, and a mechanism for handling complaints, grievances, and
special needs. This includes providing current information on how to
contact the Illinois Department of Public Health, the Joint
Commission, and Hospital Administration.
 It is the responsibility of every member of the heath care team to
ensure that every patient or their legal representative has the
opportunity to exercise their rights in accordance with applicable
law, Hospital policy, and accepted standards of patient care.
(Joint Commission RI.1 Ethics, Rights, and Responsibilities. CMS CoP Rule 482.13)
(MacNeal Hospital Patients Rights and responsibilities, 2007).
Patients Rights and Responsibilities
Patients have a right to care, treatment, and services that:
 Is medically indicated and accepted regardless of race, religion, sex,
sexual orientation, age, national origin, linguistic abilities, physical
and mental abilities or sources of payment for care.
 Is considerate of patient’s well being and respectful of their dignity.
 Allows freedom to exercise cultural and spiritual beliefs, that do not
interfere with the well being of others, as the appropriate course of
medical treatment
 Provides emergency services without deferral.
 Provides impartial access to available accommodations.
 Appropriately and aggressively manages pain.
 Is free from restraints unless medically necessary for safety.
 Gives them an opportunity to request a transfer to another room or
facility.
 Allows access to visitors and written and/or verbal communication,
unless such access impedes medical treatment.
 Is sensitive and responsive to issues surrounding terminal illness.
 May place a patient in protective care when necessary for personal
safety.
(Joint Commission RI.1 Ethics, Rights, and Responsibilities. CMS CoP Rule 482.13)
(MacNeal Hospital Patients Rights and responsibilities, 2007).
Patients Rights and Responsibilities
Patients have the right to receive information about care, treatment, and services including:
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The Patient Bill of Rights that contains information for handling and
resolving patient complaints and grievances.
The assistance of a qualified foreign or sign language interpreter.
A legally designated representative when unable to make decisions
about treatment, or unable to communicate wishes regarding care.
Knowing, by name, the physician's and other licensed independent
practitioners primarily responsible for their care.
Obtaining complete and current information concerning diagnoses,
treatments, and prognoses from the physician, in language and terms
that are understandable.
(Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule
482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).
Patients Rights and Responsibilities
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Receiving from the physician as much information as necessary to
give informed consent prior to the start of care, treatment, and
services. Except in emergencies, information should include the
specific procedure and/or treatment, potential benefits and risks, the
expected time for recovery, the likelihood of success, the possible
results of no treatment and/or procedure, and any significant
alternatives.
Refusing treatment, including life-sustaining care, and information of
the benefits, risks, and medical consequences of this action.
Receiving information during the admission process regarding and
describing Advance Directives. The Advance Directive will be
maintained in the patient’s current medical record and will be
periodically reviewed by physicians, the patient, the healthcare team,
or the legally designated decision-maker.
Information regarding ethical issues resolution.
The opportunity to participate or refuse to participate in
investigational studies or clinical trials after receiving all the
necessary information with which to make a decision.
Information about the outcome of care, treatment, and services,
including whenever those outcomes differ significantly from the
anticipated outcome.
(Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13)
(MacNeal Hospital Patients Rights and responsibilities, 2007).
Patients Rights and Responsibilities
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Patients have a right to privacy and confidentiality including:
An environment that is as safe and secure as possible.
That disclosures made to the healthcare team are kept confidential and that
any discussion or consultation is conducted discreetly.
Receiving care in an environment that offers as much visual and auditory
privacy as possible.
Refusing contact with anyone not officially connected with the hospital,
including visitors.
Request the presence of members of their own sex during examinations or
procedures performed by professionals of the opposite sex.
Only disrobing when medically necessary.
Maintaining contact with individuals outside the hospital through visitors or
by written and/or verbal communication.
Access, request amendment to, and receive an accounting of disclosures
regarding his or her own health information as permitted under applicable
law.
(Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13)
(MacNeal Hospital Patients Rights and responsibilities, 2007).
Patients Rights and Responsibilities
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Patients have certain responsibilities including:
Providing all needed information to the healthcare team to assist with
treatment, including but not limited to: nature of illness, past illnesses and
hospitalizations, medications, unexpected changes in medical condition.
Informing the healthcare team whether or not they understand the proposed
course of treatment and their role in the treatment plan.
Understanding the consequences that may result if they refuse treatments or
procedures, or do not follow the instructions from their healthcare team.
Working with the healthcare team to find the best pain relief plan and
treatment.
Following Hospital rules and regulations including: respecting the rights
and property of other patients and personnel, complying with the hospital’s
visitor policies, complying with the hospital’s smoke free environment
policy.
Providing accurate information regarding sources of payment for care
rendered. Understanding that no emergency services will be deferred
pending receipt of this information.
Fulfilling their financial obligation as promptly as possible.
(Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13)
(MacNeal
Hospital Patients Rights and responsibilities, 2007).
Ethical Issues in Patient Care
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Purpose
To provide a mechanism to address questions, conflict, or other
dilemmas for patients, family/legal representatives, and the Hospital.
MacNeal Hospital recognizes that making decisions about care,
treatment, and services may, at times, present questions, conflicts, or
other dilemmas for patients, family, other decision makers, and the
Hospital.
The Hospital is committed to working with patients, and when
appropriate, their families to resolve such issues. Any employee,
staff member, patient, family member, significant other, legal
representative or surrogate decision maker has the right to raise
ethical concerns related to patient care. The Hospital expects staff to
be sensitive to ethical concerns raised in the course of patient care
and promotes resolution to ethical issues in an atmosphere that is
comfortable and respectful to all parties involved. The Hospital
promotes ethics education and will assist staff gain expertise in
managing ethical uncertainties.
(MacNeal Hospital, Ethical issues in Patient Care, 2008).
Ethical Issues in Patient Care
Procedure
 Staff should address ethical concerns (a) first, within the
interdisciplinary team caring for the patient, (b) second, with the
clinical Ethics Consultant.
 The Ethics Consultant is available 24 hours per day by contacting
Telecommunications.
 Any staff member may request a clinical ethics consult. The
attending physician should be notified of a consult request.
 Patients and family members, or other decision makers facing ethical
dilemmas may contact any member of the health care team including
pastoral care and social services and request an ethics consult.
 Ethics consults will be performed by a qualified Ethics Committee
member or by the Ethics
 Consultant on call. The Ethics Committee member or Consultant
will recuse themselves from
 cases they are involved in.
MacNeal Hospital, Ethical issues in PatientCare,2008).
Ethical Issues in Patient Care
The consultant will:
 Review the facts of the case via chart review and
interviews with members of the medical, nursing, social
services and pastoral care staff. Patient and family
involvement in the consult is encouraged. The extent of
their involvement is on a case-by-case basis.
 Analyze the ethical issues pertinent to the case. Provide
conclusions and recommendations to the requesting
individual(s) in a timely manner.
 Educate the health care team involved about the ethical
issues identified.
 Document consultant activity in the medical record as
appropriate.
 Provide follow-up as appropriate.
 Review consultant activity at the Ethics Committee.
(MacNeal Hospital, Ethical issues in PatientCare,2008).
Health Insurance Portability &
Accountability Act (HIPAA)

What is the purpose of the HIPAA privacy
standards?
– To provide patients with control over the use
and disclosure of their patient identifiable
information
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What does the abbreviation P.H.I mean?
– Protected Health Information
(MacNeal Hospital, Notice Privacy Practices and HIPPA awareness program, 2008).
Protect all forms of patient information
Where is the PHI in the organization?
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I
Conversation
Documents
If you are in doubt or if
something doesn’t feel right,
Ask your supervisor or call
the Privacy Officer.
Computers
How to protect privacy of the
patient information on paper
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Don’t leave paper on printer's fax machines or copiers
Dispose paper, addressograph plates, labels by approved
methods
Always use a fax cover sheet with a confidentiality
statement
Only authorized staff should have access to the location
where records are stored
PHI on paper should never be left unattended in a nonsecure area
Visitors should obtain clearance upon entry and be
escorted when in areas where patient information is
stored or accessible
Key, key cards or tokens should be kept securely stored
How to protect privacy of the
patient information spoken
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Be sure you know to whom you are speaking
BEFORE you release patient information
Disclose information only to individuals with a
business need to know & only the minimum
necessary to accomplish the job
Keep your voice down. Speak so others may not
overhear
Do not leave information in patient rooms
Knock before entering a patient room
Do not speak about patient information in
hallways, cafeteria, elevators or any public area.
It’s a BIG Deal!
You need to be very good at keeping PHI
safely within your workspace, so it doesn’t
get out where it doesn’t belong
 Our patients are counting on you and I to
make sure their personal information is
protected- It’s really up to us to make sure
the right thing is happening
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References
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Ethics, Rights, and Responsibilities. (2008). Joint Commission RI.1
CMS CoP Rule 482.13
MacNeal Hospital. (2008). Ethical issues in Patient Care: Patient
care policy manual.
MacNeal Hospital. (2008). Hazardous Materials: Receiving,
Transporting, Storage and Labels. Policy number: 04-11
MacNeal Hospital: Notice Privacy Practices and HIPPA awareness
program. (2008).
MacNeal Hospital Infection Control (2006). Policy and Procedure
for the use of the pneumatic tube system for the transport of blood
products and specimens.
MacNeal Hospital Patients Rights and responsibilities. (2007).
Patient care policy
NationalPatientSafetyGoals. (2011).
http://www.jointcommission.org/PatientSafety/