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ADVANCE Perspective: Nurses

It Only Takes a Second

Published February 17, 2009 1:35 PM by Candy Goulette

When you think about how many bits of personal information hospitals and other healthcare providers gather on every patient or client who comes through their doors, it's amazing most are able to keep those bits private. A thoughtless moment is all it can take to cross that HIPAA line into uncharted and unintended territory.

So what do you do when you're on the other side of that line?

As a regional editor for ADVANCE, I'm on the road pretty often, visiting hospitals and non-acute care facilities, meeting nurses and attending meetings around the state and across the country. Everywhere I go, I hand out my business card. So far, in the nearly 5 years I've been privileged to do this work, I've passed out some 2,000 cards, complete with phone and fax. I've probably gotten back 5 times as many gathered at conferences and face-to-face meetings. I try to enter the information into my contact manager correctly; but, I have to admit, there are times when I transpose phone numbers or miss letters in e-mail addresses. When I make a mistake, I get a wrong number or the e-mail comes back. No harm, no foul, no connection.

But that's not the case when a hospital case manager makes a mistake faxing patient paperwork following discharge. That was the situation I found myself in last week. A little background: the first three numbers of my phone number - 408 - are the same as the area code for Santa Clara County, CA, including San Jose. We frequently get calls from people who forgot to dial the ‘1' before the number. I usually just remind them to dial the one and that's that.

But last week, my fax rang and the sender had made the same mistake. She had forgotten to dial the ‘1' before the number, which was to a skilled nursing facility in Santa Clara County. She was a case manager for a hospital in Sacramento, near where I live, and was trying to send a patient file to the SNF before placing the patient. When I saw the first page, I cancelled the rest of the fax and called the number listed on the sheet.

When the nurse who sent the fax answered and I told her who I was and what had happened, I could actually hear her face go pale. I reassured her I had only gotten the first page, that no sensitive patient information, save the name, had been exposed, and I was going to shred the paper immediately. She was relieved, but sounded shaken. It had been a very busy morning, she said, trying to justify her moment of inattention, but she admitted she should have paid more attention to what she was doing.

I believed her and I'm sure she learned a valuable lesson. I told her I was glad it was my fax she called in error. As I hung up, I thought about the many people I know whose phone numbers start with "408" and how often that mistake occurs. Next time, this sensitive information (including the patient's social security number and diagnosis) might fall into the wrong hands.

HIPAA may seem onerous at times - it has to me, as the family member of a patient who had to go through the "password" routine - but it's in place to protect people. The times when you're most frazzled are when you're more apt to make a mistake, even a simple one like forgetting to dial a one before the area code, so take a minute before you get to that stage and regroup. Even standing up can help you refocus your energy and attention, so what was a small mistake doesn't turn into a big mess.


Unfortunately, entering incorrect fax numbers may be more common than we would like to believe - last week my husband received a patient's information sent in error to his office fax machine in Texas. He wasn't there to cancel the incoming fax so the patient information was printed and open to the scrutiny of other people in the office.

When he returned to the office the next day and found the faxed pages, he called the sending facility to alert them of the error and shredded the pages.

In most cases of man vs machine, the only remedy or safeguard to this sort of "human" error is for the human as a matter of routine to double check the number entered before initiating the send button.

After all, a machine is usually only as accurate as the human operating it.

Trudy Schreiner March 18, 2009 1:01 PM

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February 23, 2009 7:57 AM

It seems that as our industrial society becomes more "password protected", oversight such as transposing numbers in a phone number become more common. Electronic Patient Records--EPR--are becoming the wave of the future. With that said, means to transport patient data via computer equipment are lagging behind in safeguards against user-error. Safety guards on electronic equipment are needed to reduce user-error. It would be nice if fax machines could show the physical address of the recipient prior to the user pressing the "start" button.

Bridgette Williams, , RN VAMHCS February 17, 2009 10:30 PM

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