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Safety & Policy – March 2019

Official “Do Not Use” List1

Do Not Use

Potential Problem

Use Instead

U, u (unit)

Mistaken for “0” (zero), the number “4” (four) or “cc”

Write “unit”

IU (International Unit)

Mistaken for IV (intravenous) or the number 10 (ten)

Write “International Unit”

Q.D., QD, q.d., qd (daily)

Q.O.D., QOD, q.o.d, qod(every other day)

Mistaken for each other

Period after the Q mistaken for “I” and the “O” mistaken for “I”

Write “daily” Write “every other day”

Trailing zero (X.0 mg)*

Lack of leading zero (.X mg)

Decimal point is missed

Write X mg

Write 0.X mg

MS

MSOand MgSO4

Can mean morphine sulfate or magnesium sulfate

Confused for one another

Write “morphine sulfate”

Write “magnesium sulfate”

Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.

*Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

Development of the “Do Not Use” List

In 2001, The Joint Commission issued a Sentinel Event Alert on the subject of medical abbreviations. A year later, its Board of Commissioners approved a National Patient Safety Goal requiring accredited

organizations to develop and implement a list of abbreviations not to use. In 2004, The Joint Commission created its “Do Not Use” List to meet that goal. In 2010, NPSG.02.02.01 was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.01.

For more information

TRS HEALTHCARE PROVIDER HIPAA TRAINING POLICY

Purpose: The TRS Healthcare Provider will be knowledgeable about HIPAA and the information that the Privacy Rules protects.
Definitions:
HIPAA –The American Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides federal protections for individually identifiable health information held by covered entities and their business associates. HIPAA give patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes. These rules apply to “covered entities” including AmediStaf, L.L.C.,
and The Right Solutions.
HITECH – The Health Information Technology for Economic and Clinical Health Act expands the obligations of health care providers to protect patients’ protected health information. Business associates are separately and directly liable for violations of these rules.
PHI – Protected Health Information includes any information about health status, provision of health care, or payment for healthcare that can be linked to a specific individual.

The HIPAA privacy rules call for covered entities to enter into written agreements with their business

associates, defined as any individuals or organizations that have access to Protected Health Information (PHI) as a result of providing services to that covered entity. As a healthcare travel professional of TRS Healthcare you will have to:

  • Be careful to avoid discussing information about a person with co-workers who may not have a “need to know”.

  • Be careful to avoid discussing information about a person in public areas, or in telephone

conversations that can be easily overheard by others.

  • Keep and protect written information in the work environment about a person away from

the eyes of others who do not have a “need to know.”

  • Make sure that casual visitors can’t just wander into areas in which clinical information

about a person is kept.

  • Know when information about a person can be shared without the person’s permission, and

when the person has to give written or oral permission to share information.

  • Make sure that if you have computer access to confidential/private information about a

  • follow all policies/procedures for maintaining the confidentiality and security of the information.

person, you

Training Scenarios:

  1. Can a provider in a healthcare organization use an electronic database to access the medical record of patient who was seen by another provider in the organization? Yes, as long as the provider will be treating that patient or is assisting another provider with the coordination of the patient’s care.
  2. If a healthcare professional describes a patient on a social media site with sufficient detail to be identified, would this be a HIPAA violation? Yes, this would be considered a breach of patient confidentiality or privacy.
  3. A healthcare professional discloses private information about a patient to one intended recipient. Could this be considered a breach of confidentiality? Yes, this too is a breach of confidentiality and patient privacy.
  4. During shift report, the healthcare provider communicates the name, diagnosis, treatment plan, and current medications to the oncoming healthcare provider who is to care for the specific patient. This would not be a HIPAA violation as that provider has a reason to know the patient’s health information.
  5. A healthcare professional is working with a pediatric patient and is “entertaining” him with her cell phone and takes his picture. She later shares this picture with her clinical group telling them about his diagnosis, room number, etc. HIPAA and nurse practice act standards are compromised by these actions.
  6. A healthcare professional submitted information to a local newspaper’s online chat room containing information about the patient she cared for that day. As it was a small town and information was released that could identify the patient, this was a violation of patient confidentiality.

 

 

 

 

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