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National Patient Safety Goals


The Hospital is committed to working with patients, and when appropriate, their families to resolve such issues. Any employee, staff member, patient, ... – PowerPoint PPT presentation

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Title: National Patient Safety Goals

National Patient Safety Goals
  • Mac Neal Hospital
  • 2011

National Patient Safety GoalsPurpose
  • The purpose of The Joint Commissions 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
    expert-based solutions to these problems.
  • The Requirements focus on system-wide solutions,
    wherever possible.

2011 National Patient Safety Goals
  • Approved by The Joint Commissions Board of
  • The Goals and Requirements are program-specific
  • 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
  • Improve the accuracy of patient identification

Patient Identification
  • Use at least two patient identifiers (name
    birth date) when providing care, treatment and
  • 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

Patient Identification
  • Eliminate transfusion errors related to patient

Improve Communication
  • Get the important test results to the right staff
  • 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.

Improve Communication
  • The organization implements a standardized
    approach to hand-off communications, including an
    opportunity to ask and respond to questions.
  • 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 look-alike/sound-alike
    medications used by the organization and takes
    action to prevent errors involving the
    interchange of these medications.

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.

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

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
  • Implement evidence-based practices to prevent
    health care associated infections due to multiple
    drug-resistant organisms in acute care hospitals.

Health Care Associated Infections
  • Implement best practices or evidence-based
    guidelines to prevent central line-associated
    bloodstream infections.
  • Implement best practices for preventing surgical
    site infections.

Reconcile Medications
  • 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 patients meds to their new
    care giver. Give the list to the patients
    primary doctor before the patient goes home.
  • Give a list of the patients medications to the
    patient and their family before they go home.
    Explain the list.

Reconcile Medications
  • In settings where medications are used minimally,
    or prescribed for a short duration, modified
    medication reconciliation processes are

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.

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.
  • (Joint Commission, 2009)

Influenza Pneumococcal Disease
  • The organization develops and implements
    protocols for administration of the pneumococcus
  • The organization develops and implements
    protocols to identify new cases of influenza and
    to manage outbreaks.
  • (Joint Commission, 2009)

Surgical Fires
  • 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.

Pressure Ulcers
  • Prevent health care associated pressure
  • ulcers (decubitus ulcers)
  • Assess and periodically reassess each residents
    risk for developing a pressure ulcer (decubitus
    ulcer) and take action to address any identified

Risk Assessment
  • The organization identifies safety risks
  • inherent in its patient population.
  • The organization identifies patients at risk for
  • The organization identifies risks associated with
    home oxygen therapy such as home fires.

Changes in Patient Condition
  • Improve recognition and response to changes in a
    patients 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 patients
    condition appears to be worsening.

Universal Protocol
  • 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

Utility Failure-CODE GREENReporting Utility
  • 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
  • Facility Services will
  • Inspect the situation
  • Initiate corrective action

Other Utility Failures
  • Contingency plans are in place for utility
  • ...Ask supervisor for details

Power Failure- Main Campus
  • Main Campus power disruption
  • Emergency generators automatically start
  • Emergency power in 10 minutes or less
  • Generators
  • Provide power to the main campus in emergencies
  • For more than 24 hours
  • Coverage includes
  • Critical medical equipment
  • Emergency lighting
  • Designated elevators
  • Red outlets
  • Battery power lights
  • Provides illumination
  • Provides safety for generator turns on emergency

Power Failure- Main Campus
  • Connect critical components into RED outlet (IVs

Power Failure Off-Site Facilities
  • Battery powered lights
  • Illumination for up to 1 hour
  • limited illumination for exiting premises
  • Facilities with generators which support a
    limited amount of equipment
  • Harlem- Ogden bldg
  • Mid City Bank bldg

Telephone System FailureMain Campus
  • The red telephones may be the only working
  • Used as a back up system
  • Separate phone numbers are attached to each red

Oxygen/ Medical Air/ Suction Shut- off Valves
  • Shut-off valves are located throughout the
    hospital in areas where services at off valve
  • 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

Electrical Safety Considerations
  • Dont 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

Reporting Electrical Hazards
  • Immediately report any non-static electrical
    shocks to your supervisor
  • Unsafe equipment should also be reported
    immediately to
  • 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
  • The Device Tracking Regulation
  • The Medical Device Reporting (MDR) Regulation

Definition of Medical Device
  • A Medical Device is
  • Any device used in the treatment, therapy or
    diagnosis of patients

Medical Devices Include

Hospital Bed
  • Infusion pumps,
  • defibrillators, monitors,
  • implantable devices
  • Beds, syringes, IV lines,
  • wheelchairs

Device Tracking Regulation
  • Certain Medical devices are required by the FDA
    to be tracked.
  • IV pumps
  • Implantable devices
  • pacemakers

Medical Device Reporting (MDR) Regulation
  • Medical Device Reporting is required
  • If a device may have contributed to a patient or
  • Death
  • Serious injury
  • Serious illness

General GuidelinesMedical Device Incident
  • 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

General Guidelines Medical Device Incident
  • 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
  • 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
  • Serial numbers
  • Identification numbers

General Guidelines Medical Device Incident
  • Save all the materials
  • Dont 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

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
  • Additional labels can be obtained by calling that

M.S. D. S. Hazard Rating Label Determination
  • Red Flammability
  • Blue Health
  • Yellow Reactivity
  • White Specific Hazard

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
  • Move to a safe location
  • Contact your supervisor
  • Await further instructions

Biohazard Items
  • Biohazard items include and are not limited to
  • Syringes
  • Blood
  • Blood and body fluid specimens

  • 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.
  • 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
  • All specimens must be placed in an appropriate,
    sealed container.
  • (MacNeal Hospital Infection Control Policy and
    Procedure for the use of the pneumatic tube
    system for the transport of blood products and
    specimens , 2006).

  • 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
  • Sterile Processing will decontaminate the zip
    lock bag and/or the tube in the event of
  • (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
  • 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
  • Hand Carry
  • Specimen in plastic specimen bag
  • 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

Hazardous Materials Receiving, Transporting,
Storage, and Labels
  • Policy
  • The following precautions shall be observed in
    receiving, transporting, and storing hazardous
  • 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

Hazardous Materials Receiving, Transporting,
Storage, and Labels
  • Transporting
  • Securely cap or seal hazardous drugs in specially
    labeled containers and protect them during
  • 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

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

Disposal ?
  • Chemicals and hazardous waste must be disposed
    of according to local regulations and MSDS

Code Event Code Designation
  • Code Red
  • Fire
  • Code Blue
  • Medical Emergency-Cardiac Arrest
  • Code Blue- Pediatrics
  • Pediatric Emergency
  • 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
  • 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
  • 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 ones 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
  • 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
  • Is considerate of patients 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
  • 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
  • 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
  • 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 patients 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
  • (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 privacy and
    confidentiality including
  • An environment that is as safe and secure as
  • 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
  • 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
  • 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
    hospitals visitor policies, complying with the
    hospitals 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,

Ethical Issues in Patient Care
  • 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
  • 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
  • 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

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
  • (MacNeal Hospital, Ethical issues in

Health Insurance Portability Accountability Act
  • What is the purpose of the HIPAA privacy
  • To provide patients with control over the use and
    disclosure of their patient identifiable
  • 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?
  • I

If you are in doubt or if something doesnt feel
right, Ask your supervisor or call the Privacy
How to protect privacy of the patient information
on paper
  • Dont leave paper on printer's fax machines or
  • 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
    non-secure 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

How to protect privacy of the patient information
  • 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
  • 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.

Its a BIG Deal!
  • You need to be very good at keeping PHI safely
    within your workspace, so it doesnt get out
    where it doesnt belong
  • Our patients are counting on you and I to make
    sure their personal information is protected-
    Its really up to us to make sure the right thing
    is happening

  • 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).
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