Addressing a Patient Safety Issue- HIPAA-Privacy Violation

For quality and safe healthcare to be offered to patients who visit a healthcare facility, several healthcare professionals must collaborate and communicate to ensure the delivery of efficient care to their clients. These healthcare professionals must adhere to healthcare regulations to ensure that patient safety is maintained and promoted. A patient safety officer is tasked with the responsibility of addressing any safety concerns within a healthcare organization and ensuring that healthcare professionals follow laid-down policies and protocols. The duty of a patient safety officer is to conduct safety rounds and observe any inappropriate practices that may compromise patient safety. Patient privacy is an important aspect of patient safety. The patient safety officer must thus address violations to patient privacy which may affect the safety and quality of healthcare services

Health Care Safety Imperative

Privacy to patient information is imperative. All healthcare professionals working directly with patients must ensure that they uphold the privacy of patient information and minimize access by unauthorized personnel. All healthcare professionals that can access patient records, hospital systems, and information that may have protected health information must understand healthcare policies that govern the privacy of patient data. Patient privacy is an ethical principle that ensures the confidentiality of patient information is protected (Noroozi et al., 2018). Healthcare professionals must keep to themselves whatever information they come across during the course of providing care for patients.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that sets standards and regulations that protect the disclosure of patient healthcare records and information without the consent and knowledge of the patient (Cohen & Mello, 2018). The scenario, in this case, involves violations of HIPAA rules. A nurse posted the details of a patient condition in her Facebook account. According to the CDC vaccination guidelines and schedule, the patient in question was still young and could not receive the measles vaccination. The child contracted measles before vaccinations. On admission, the patient presented with a high fever and painful rash. The nurse posted the details of the patient’s condition on social media. She is an anti-vaxxer and tagged her fellow anti-vaxxers. She stated that the patient getting measles did not change her opinion on vaccination. She further wrote that she could not comprehend why parents immunize their children out of fear of medical conditions. Even though the nurse did not include the patient’s name, her place of work was listed on her Facebook profile. One of her Facebook friends also had a child hospitalized in the same hospital. This parent was worried that her child might contract measles and alerted the hospital administration. Upon realizing this, the nurse deleted this post.

If the hospital administration fails to address this threat to patient safety, the regulatory agency in charge of HIPAA violation may impose sanctions and penalties on this organization. Penalties vary depending on the nature of the violation (Edemekong et al., 2021). This includes whether the staff member knew it was a HIPAA violation or an act of neglect of sharing protected health information. Penalties related to the HIPAA privacy rule could cost the employee and the hospital fines or even jail time. Fines include $50 000 or one year of jail time.

Risks if Threats not Addressed

HIPAA violations gave negative consequences on patients. Patients who feel that hospitals cannot safeguard the safety of their protected medical information may lose trust in the healthcare organization. This will result in the reduction of patient satisfaction and negative patient outcomes. Furthermore, releasing sensitive patient information may lead to stigma and shame. Some healthcare conditions such s HIV/ AIDS are still associated with stigma. Patients whose HIV status is revealed may face societal stigma, resulting in mental health issues such as anxiety, depression, stress, and suicidal ideation.

HIPAA violations also affect employees who have committed the violations. There are four potential consequences for violating HIPAA rules. They include internal investigation, termination of employment contracts, sanctions from professional boards, and criminal charges, including fines and jail terms. The civil penalties for violating HIPAA rules start at 100 dollars for a person who violates the regulations (Edemekong et al., 2021). The fine can rise if there are multiple violations. These financial penalties are applied when an employee knows that he is violating HIPAA rules. The criminal penalties for violating HIPAA violations are severe. The minimum fine for violations is $ 50,00, while the maximum financial penalty is $ 250 000 (Edemekong et al., 2021). The employee may also be asked to compensate the patient. In addition to the fine, an individual may also be jailed for criminal violations. Criminal violations due to negligence can result in a jail term of up to one year, while knowingly violating the regulation for personal gain or malicious intent can lead to a jail term of up to ten years (Edemekong et al., 2021).

Intentional violations of HIPAA rules can cost a healthcare organization millions of dollars. The regulatory agency may fine a hospital thousands to millions of dollars per violation of HIPAA rules. Financial penalties are different depending on the severity of negligence of a covered entity. If the violations are determined to be intentional, covered entities can be fined a maximum of $ 1.5 m yearly (Edemekong et al., 2021). The organization may also lose income. Medicare is one of the largest medical payment providers in the United States. Failure of a healthcare organization to comply with HIPAA rules may result in withholding Medicare payments.

The Office of Civil Rights (OCR) enforces and implements the HIPAA privacy rule concerning compliance activities and financial penalties. The OCR investigates patient privacy compliance and audits hospital rules regarding patient health information (HIPAA Journal, 2022). The effect of an OCR investigation will allow a hospital to provide evidence on the violations that would help reduce penalties. Evidence should be submitted within 30 days of receipt of notification. The OCR can also assist with voluntary compliance (HIPAA Journal, 2022)

Regulatory Agency Role and Impact

The standards of the Joint Commission require healthcare organizations to comply with laws and regulations to protect the integrity and privacy of confidential information (Joint Commission, 2019). When a hospital staff is not available to monitor storage areas of medical records, an alternative strategy must be employed to protect the confidentiality and privacy of this information. The use of alternative strategies may include locking mechanisms. The risk management team should extensively assess the use of these alternative strategies to ensure they comply with state regulations and CMS (Joint Commission, 2019). All hospital areas should have systems in place that maintain the integrity and security of patient information. The systems adopted must be subjected to security audits to help identify policy violations and vulnerabilities (Joint Commission, 2019). Healthcare organizations should also adhere to their policies regarding the security of patient information.

Accreditation is important in healthcare. Accreditation is done by regulatory agencies. Healthcare organizations implement their patient safety programs to ensure they align with the requirements of the accrediting agencies. The internal standards and rules must be recognized by the accrediting agencies. Accreditation is a stamp of approval that shows that a healthcare organization follows the best practice standards (Jha, 2018). Regulatory agencies ensure that healthcare organizations implement patient safety standards that enhance the quality of care and promote patient safety. Before accreditation, health organizations must conduct a comprehensive evaluation of their programs and policies to identify areas that show gaps in compliance.

Patient Safety Officer’s Role

The role of the patient safety officer is to implement strategies to protect the privacy of patient health information (Van de Ruit & Bosk, 2020). A safety officer promotes continuous learning to maintain high-quality standards in the hospital environment. A safety officer collaborates with other healthcare professionals to conduct risk assessments of a hospital’s privacy policies. The primary goal of a safety officer is to provide a plan of action (Van de Ruit & Bosk, 2020). This plan of action will enhance standards of procedures that improve the integrity of patient privacy. He will help clinical leaders to update their practice techniques to minimize patient safety threats like HIPAA violations. The safety officer will follow HIPAA privacy rules when solving the issue. He will meet with the patient’s parents to document the complaint. The next step will involve informing the hospital’s risk manager of the complaint. The parent will be informed of the nurse’s mistake and directed to the hospital legal department for resolution. The nurse will be taken to the disciplinary committee for appropriate disciplinary action.

Evidence-Based Best Practice Recommendations

All staff handling patient information will be involved in updating policies concerning the privacy of patient health information. The current hospital policy is outdated. A compliance program for all healthcare professionals to participate in will be established. This tool will allow all healthcare professionals to give feedback and understand the importance of ensuring the privacy and confidentiality of patient information. Departmental heads will readdress user privileges and train their subordinates on proper social media use in the workplace. The user privileges will only allow authorized staff members to access protected health information. The departmental heads will be tasked with reviewing these user privileges. The departmental heads will also educate their subordinates on HIPAA rules and penalties for violating them. Developing new privacy policies will promote the commitment of staff members to comply with HIPAA regulations. Staff members will be enrolled in a training program to increase their knowledge of HIPAA compliance. This action plan to reduce HIPAA violations will help address potential risks to the privacy of patient information. The final step on the action plan will be conducting regular risk assessment exercises to determine the level of compliance of healthcare professionals to the new hospital policy.

Conclusion

One of the primary goals of healthcare delivery is to ensure patient privacy. However, this is not the case since many patient privacy violations are reported. Healthcare organizations should implement strategies to comply with HIPAA regulations concerning the privacy of patient information. They must involve a patient security officer to guide them in formulating strategies to minimize patient safety risks. The strategies implemented must comply with accrediting agencies and regulatory agencies.

References

Cohen, I. G., & Mello, M. M. (2018). HIPAA and protecting health information in the 21st century. JAMA, 320(3), 231. https://doi.org/10.1001/jama.2018.5630

Edemekong, P. F., Annamaraju, P., & Haydel, M. J. (2021, February 4). Health Insurance Portability and Accountability Act – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK500019/

HIPAA Journal. (2022, January 7). Who enforces HIPAA? https://www.hipaajournal.com/who-enforces-hipaa/

Jha, A. K. (2018). Accreditation, quality, and making hospital care better. JAMA, 320(23), 2410. https://doi.org/10.1001/jama.2018.18810

Joint Commission. (2019). Medical Record – Security. Leading the Way to Zero | The Joint Commission. https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/information-management

Noroozi, M., Zahedi, L., Bathaei, F. S., & Salari, P. (2018). Challenges of Confidentiality in Clinical Settings: Compilation of an Ethical Guideline. Iranian journal of public health, 47(6), 875–883.

Van de Ruit, C., & Bosk, C. L. (2020). Surgical patient safety officers in the United States: Negotiating contradictions between compliance and workplace transformation. Work and Occupations, 48(1), 3-39. https://doi.org/10.1177/0730888420930345

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Addressing a Patient Safety Issue- HIPAA-Privacy Violation

Health Care Safety Imperative

[Apply the health care safety imperative to a patient safety issue.]

Risks if Threats not Addressed

[Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.]

Regulatory Agency Role and Impact

[Analyze regulatory agencies’ role and impact on organizations’ patient safety programs.]

Patient Safety Officer’s Role

[Analyze the patient safety officer’s role in implementing patient safety plans.]

Evidence-Based Best Practice Recommendations

[Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.]