For any offense, a preliminary investigation will precede assignment of level of violation. Level of Violation Examples Minimum Disciplinary/Corrective Action Level I Misdirected faxes & emails Failing to log-off, close or secure a computer with PHI displayed Leaving a copy of PHI in a non-secure area Dictating or discussing PHI in a non-secure area (lobby, hallway, cafeteria, elevator, etc.) Failing to redact or patient information for operational/business uses Transmission of PHI using an unsecured method, Leaving detailed PHI on an answering machine. Improper disposal of PHI. First offense: written counseling by Program Director and notification of DIO. Second offense within one year: written warning by Program Director with copy to DIO and GMEC. Notify Privacy Officer of all incidents. Level II Requesting another individual to inappropriately access patient information Inappropriate sharing of ID/ password with another or encouraging to share ID/password Failure to secure data on mobile devices through encryption/password protection. First offense: written warning by Program Director with copy to DIO. Written warning plus corrective action plan by DIO and copy to Chair and President of Staff. Notify Privacy Officer of all incidents. Level III Releasing aggregate patient data without facility approval for research, studies, publications, etc. Accessing or allowing access to PHI without having a legitimate reason Giving an individual access to your electronic signature Accessing patient information due to curiosity or concern, Written notification of probation by Program Director, or Department Chair, or DIO (See GME Policy Manual), with notification of President of Medical-Dental Staff; or President of Staff appoints ad hoc group for investigation, potential disciplinary worker worker
Nails no longer than ¼ inch. Bacteria can reside under the nails and around chipped nail polish, even with appropriate hand hygiene, which has been associated with outbreaks at some hospitals. Respiratory etiquette: Cover nose/mouth when coughing or sneezing. Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use. When tissues are not available, cough into fabric such as your sleeve. Cover your cough with your arm, not your hand. Perform hand hygiene (e.g., hand washing with water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials. Standard Precautions Standard Precautions Apply to 1) blood; 2) all body fluids, secretions, and excretions except sweat, regardless or whether or not they contain visible blood; 3) non-intact skin; and 4) mucous membranes. Considers all patients and all body fluids as potentially infectious. Prevents transmission of HIV, Hepatitis B Virus, Hepatitis C Virus, and other bloodborne pathogens. Require use of appropriate personal protective equipment (PPE) to protect yourself from exposure. PPE (gowns, gloves, face shields/safety eyewear, masks, and shoe covers) is worn to protect skin/clothing from coming into contact with blood or other potentially infectious material. PPE should only be worn in procedure areas and patient rooms. PPE in public areas such as the cafeteria, elevators and lobbies is not acceptable as it is a potential vector in transmission of pathogens and may be perceived as lacking professionalism. Key points about PPE Don before entering the room Remove and discard carefully, either at the doorway or immediately outside the patient room; remove respiratory outside room. Immediately perform hand hygiene. Sequence for donning PPE (combination for PPE required for task will affect sequence) Gown first Mask or respirator Goggles or face shield Gloves extended over gown cuffs Sequence for removing PPE (Front of PPE will be contaminated. The back ties and straps are considered clean): Peel gloves away from hand, turning glove inside out.