Sunday, February 1, 2009

Week Five Online Challenge

Our next topic is confidentiality. Your first thought probably is of HIPAA - that is probably what should come to mind. This week's challenge asks you to write about your own experiences with confidential medical information - in the ED or elsewhere.

Write a personal vignette of a time when you or someone else on the care team breached or almost breached a patient's right to confidentiality. Some things to write about include: What was the situation? Did you or anyone else do anything about it? How might this be avoided in the future?

I'll start off with one of my own stories in the first comment.


  1. While observing in a University ED during interview season, I was passed an organ donation card that belonged to one of the patients. The card had a standard statement at the top and then room for the individual to list exceptions of additions. The standard section read, "I have spoken to my family about my intent to donate my organs" which had the addendum in beautiful script, "except for my penis, which I leave for my loving wife, ... "

    A wave of hushed giggles passed through the department before a nurse returned the card to the patient's personal belongings. About the only thing I could do is not laugh and try to return the card to someone who would appropriately store the card. I did not succeed at this latter goal.

  2. Sorry Tom, I had to laugh at that one too.

    I suppose one time when I consistently had problems with confidentiality and patient privacy was before medical school when I worked as a medical assistant. The biggest trouble came about when I had to discuss test results over the phone. Oftentimes it wasn’t the patient who would answer the phone and they would say “Oh you can tell me the results and I can tell him when he gets in.” Of course, I had no idea who was answering the phone and whether or not the patient wanted their results to be given to this person.

    One experience which has always stuck with me was a situation with an older guy who came in to be tested for HIV. At some point during his visit he had told someone that we could call him and leave the results on the phone, but this was not passed on to me. The test results came in on a Friday but when I called him I had to leave a message and didn’t indicate the results (negative for HIV). Understandably, he called back to get the results but couldn’t reach our offices because they had closed and then couldn’t reach us until Monday morning. He was infuriated by then, having had spent the entire weekend worried, and cursed out the receptionist and myself when he finally reached us on Monday. In this case there was no breach of confidentiality, and instead, the failure and frustration came about because of rigid attempts to preserve confidentiality.

  3. Both of the stories above are ones I can completely relate to - Tom I had to giggle to... :-)

    I strongly believe that HIPPA is vital to patient safety and their confidence in the medical system. With that being said, in the ED it is very hard to maintain the same level they would in any other setting.

    I can think of many challenging situations, but there is one that always occurs that I would love input on.

    An intubated patient comes in to the ED, no ID, no clothes, no one anywhere knows who this person is and they are very sick. We give them a last name of DOE, then SW and registration work to find names; finally a possible name comes in (SPD, SFD, etc.) Then we literally just start calling any number we can find. Once we find a "possible" relative, partner, etc. we ask them to come in and ID the person. The case I am thinking of was on a very busy night and we had a MCI after an apartment fire.

    A female came in intubated and without a name, so we gave her one: Jane DOE. After a search and possible a lead name, SW brought a man back to see his "possible" wife rescued from the fire. Now to us seeing a mangled bloody body is another day at work, for this young man, (25 at most), I think it was the first - after studying her face for a long while, he looked up with a blank stare and said it wasn't her. His eyes pooled tears as he left the room.
    I felt for him, but more so for our patient. In her most vulnerable moment, a stranger was brought in to view her. It just seemed and felt wrong. (Ethical Confusion?)

    Quite honestly I am still not sure how to remedy this situation - she had no tattoos or noticeable birth marks to reference. (As a side note, if you ever wanted a tattoo and didn't, this is a very good reason to :-)

    Anyone have ideas?

  4. These are each tough situations.

    Bryce: I know that several clinics refuse to give HIV results by phone. Probably to avoid situations like this. But I would want to know the result! (Other clinics want to provide appropriate additional support in case of a positive result.)

    Nutrire: What a case of Moral Sadness. For the man, the woman (& her family), and the team. I think the team approached this creatively. Anyone else have ideas?

  5. I remember when HIPPA first went into effect... there was a lot of weird things that went on as people tried to figure out proper compliance.

    The greatest story was a third hand story that was passed around for a while...
    I guess in some Rural EMS systems, the effects of the new law were very difficult. Out there fire and EMS crews were often volunteers who had lived in the area their entire lives, and had never had to use these things we call "addresses" to find places. The dispatcher would just say "there's a brush fire out at the Johnson place". Or "unknown medical at Mrs. Springers house out on Jackson."
    So directly after implementation of the law, dispatchers were told to only use postal addresses over the air, and nobody could find anything.
    I think they got it sorted out eventually.. but I always think of it when I think of HIPPA.

  6. This is common knowledge - but communal areas, especially in the hospital, are areas where medical personnel could violate HIPAA.

    All the hospital elevators have signs warning about confidentiality. Although I've been aware of these signs for a long time, last quarter my ICM group nearly had a slip up. After morning rounds at Harborview, our team discussed the cases during our elevator ride. At that time, we were the only people in the elevator, but shortly after the elevator stopped on another floor & more people boarded. In our excitment (or stupidity) we continued to discuss the case until our Attending quickly silenced us. We completed our discussion in a secluded area.

  7. For me, near (or violations of the spirit if not the intent of the law) breaks of HIPAA end up being common. At the end of a long day, or a long weekend moonlighting, I like to decompress and discuss the patients I cared for and what I did. When I started going back to school, the only time I had to discuss things was over coffee with my friends. This often means that we talk about cases in coffee shops, or over meals at a restaurant. And since my wife, and my friends spouses are all in medicine, we think it's "okay" to have these discussions because we aren't really breaking the law (although we really are by talking about the patient to someone not involved in his/her care).

  8. I used to work in a local hospital where much effort was taken to maintain patient confidentiality and yet other, simple things where overlooked (for various reasons including logistics, efficiency, etc).

    For example, the hospital had signs up at every service desk asking patients to stay behind a certain point to ensure the privacy of the person ahead of them while speaking with the receptionist (or whomever). But when a patient was late, many of the staff would often call out his/her name (first and last) at the top of their lungs. Also, in our CSR/discharge area, up to half a dozen patients might, at a given time, be scheduling tests,visits, etc within earshot of one another.

    Space is quite limited to be sure, but with all the time and money spent to uphold HIPAA, you'd think simple things like these wouldn't be so quickly forgotten.

  9. One issue in confidentiality that I have seen in the hospital is the availability of patient info that is written up on the common board for the staff to see. Test results and information from many different sources needs to be consolidated for the staff, and so these "communal" boards provide a necessary function. But in a busy ER, it's hard (if not impossible) to place these boards in a location that only staff can see. It's also necessary to keep SOME identifying info up there, because otherwise it's very easy to get patients confused if they only get referred to by their bed number.

  10. It is often hard to withhold information from someone who is honestly interested in the best interest of the patient, but who you do not have permission to share information with. When talking about this situation with my roommate who is a nurse in the UW cardiothoracic ICU, she told me about a time that she had a patient who was very ill and who had no family around, but had a boyfriend who kept calling to see how the patient was doing. However, since she hadn't given permission to release information and he was not a family member, she was not allowed to say anything. The boyfriend continued calling, obviously worried about the patient, and was very upset with her for not giving out information, but she was not allowed to do so under HIPAA.

  11. Talking between different health care professionals can be difficult in certain settings. Theses settings include breakrooms, hallways, elevators and many others. It is important to remember where the converstation is occuring to protect patient confidentiality.

  12. I can't say that I've really ever been confronted with a breech of confidentiality. However, while I volunteered at Mary Bridge Children's Hospital for a few years, I did bump into someone I knew who was a patient there. As a volunteer I'm allowed to know very little about their case. Nonetheless, I felt like they were embarrassed and thought I knew everything about them. It made our interactions very awkward.

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  14. I thought I'd mention the shift change report as an example of when confidentiality might be compromised. At times, I think we forget to use our "inside voices" when giving report. I am willing to bet that patients, whom are in beds directly in front of the nurses station, can hear us discuss each patient that is in the room during shift change. While we may think that we are only telling the nurses about to come on shift, it is very important to ensure patient privacy by not speaking too loudly when discussing patient treatment, etc when other patients are able to overhear the conversation.