Safety and Compliance Flashcards

When a healthcare facility conducts a Security Risk Analysis under HIPAA's Security Rule, which systems must be evaluated?

Answer: All systems that create, receive, maintain, or transmit electronic PHI (ePHI)

The HIPAA Security Rule requires a comprehensive risk analysis covering all systems that handle ePHI, not just the primary EHR.

An employee reports that they feel unsafe due to a workplace violence threat. Under OSHA guidelines, the employer's FIRST obligation is to:

Answer: Investigate the report and implement controls to protect the employee

OSHA's General Duty Clause requires employers to provide a workplace free from recognized hazards, including workplace violence threats, and to take corrective action.

In a healthcare setting, 'chain of custody' documentation for a specimen is critical because:

Answer: It ensures the specimen's integrity and legal admissibility by tracking every handler

Chain of custody documents who handled a specimen at every step, preserving its integrity and ensuring results are legally defensible.

Which of the following best describes 'scope creep' as a compliance risk in healthcare?

Answer: Staff performing tasks beyond their licensed or authorized scope of practice

Scope creep occurs when staff perform duties outside their legal and credentialed scope of practice, creating liability and patient safety risks.

A facility's infection control officer notes that hand hygiene compliance has dropped to 60%. The most effective evidence-based intervention is:

Answer: Implementing a multimodal improvement strategy including education, feedback, and role modeling by leaders

The WHO and CDC recommend multimodal strategies — combining reminders, accountability, education, and leadership modeling — as the most effective approach to improving hand hygiene compliance.

Under the Americans with Disabilities Act (ADA), a healthcare employer must provide reasonable accommodation to a qualified employee with a disability unless:

Answer: The accommodation would cause undue hardship to the organization

Employers must provide reasonable accommodations unless doing so would result in significant difficulty or expense — defined as 'undue hardship' — considering the employer's size and resources.

During a survey, a Joint Commission surveyor asks staff to describe the organization's two patient identifiers. The correct response includes:

Answer: Patient name and date of birth (or medical record number)

The Joint Commission's National Patient Safety Goals require use of at least two patient identifiers — typically name and date of birth or medical record number — before providing care or services.