Russell Birth Records

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					                                          Russell County Hospital
                                             1610 Dowell Road
                                          Russell Springs, KY 42642
                                               270-866-4141

DEPARTMENT:      Laboratory                                   Issued: Unknown
                                                              Revised: 6/30/02, 7/21/04, 5/1/06
POLICY/PROCEDURE TITLE                                        Supercedes:
Laboratory Security                                           Prepared by: R. Johnson
                                                              Approved:                      Reviewed:

                                                              Medical Director
POLICY/PROCEDURE NUMBER:                                      Approved:                    Reviewed:
400-EC -201
                                                         Laboratory Director
_________________________________________________________________________________________________

I.      POLICY. Laboratory personnel will employ the following practices to ensure the safety and security of
        employees, patients, and sensitive information:

        A. All patients must be properly identified before obtaining specimens for testing:

            1.   Ask the patient to state his full name, and if necessary, his date of birth. If the patient cannot
                 speak for himself, ask a visitor, if possible, to ID the patient.

            2.   Check the patient’s identification bracelet and ensure it matches the name given by the
                 patient. Compare it to the patient information on the specimen collection label, ensuring the
                 name, DOB, and the admission number all match.

            3.   If there is any discrepancy, STOP and resolve it before collecting the specimen.

            4.   If there is an emergency and the patient’s identification cannot be verified, affix a pink blood
                 bank bracelet to the patient’s arm and use that for temporary identification before collecting
                 the specimen.

        B. Laboratory employees must wear their name badges, above the waist and visible, at all times
           when on duty. This is critical when the employees must enter patient care areas.

            1.   If the employee forgets her badge, she may be asked to return home to retrieve it.

            2.   If the employee loses her badge, she should report Environmental Services as soon as
                 possible to get a new one made. ES will issue a temporary badge until a permanent badge
                 can be issued.

        C. Vendors must report to Materials Management to sign in and be issued a vendor ID badge
           BEFORE visiting the Laboratory. Instruct vendors in this protocol if they attempt to visit the
           Laboratory without an ID badge.

        D. Inspectors who present to the laboratory are required to furnish proper identification (photo ID)
           upon arrival and cannot be allowed entrance to the laboratory or allowed access to any
           information about the laboratory until identification and purpose of visit is verified.

            1.   Ask for the individual’s name and agency he or she represents.
            2.   Ask for the purpose of the visit and under what law, regulation, or other authority the individual
                 is acting.
            3.   Ask for the individual’s photo ID and explain that you will make a copy of it.
            4.   Contact the individual’s agency to verify the individual’s identity and purpose for the visit.


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RUSSELL COUNTY HOSPITAL
Policy/Procedure Title:             LABORATORY SECURITY
Policy/Procedure Number: 400-EC-201               Issued: Unknown                        Revised: 5/1/06

        E. Contractor workmen must report to Maintenance to be issued an “Authorized Contractor” badge
           before entering the Laboratory. Send any workman without a badge to Maintenance.

        F.   Visitors/outpatients. Visitors who do not have a legitimate reason to be in the Laboratory should
             be asked to leave. Do not allow non-laboratory employees to linger in the department. If you
             have a visitor, please stay with that person until he leaves.

        G. If lost items belonging to patients, visitors, or employees are found and the owner cannot be
           located, turn in the items to Environmental Services department, where they can be properly
           secured.

        H. Confidential information.

             1.   Patient information must not be shared with those who have no need to know. Laboratory
                  personnel have wide access to patient information and must be especially careful to
                  safeguard this privileged information.

             2.   Patients or physicians (who are not primary care or consultants) who need access to medical
                  records should report to Health Information Management (Medical Records).

        I.   Keys. Laboratory personnel have access to Central Stores, both Lab storage rooms, the Medical
             Arts building, and the Medical Arts Laboratory. These keys must be secured at all times. Always
             return the keys to the key box when they are no longer needed.

        J.   Lock the laboratory door when lab personnel are out of the laboratory. The laboratory director will
             give the door lock combination to each of the laboratory employees, who are not to share this
             information with anyone else.

        K. Theft prevention.

             1.   Avoid bringing anything of value to work that cannot be secured - you may risk losing it! This
                  includes purses, expensive clothing, jewelry, and any other items of value.

             2.   Keep only a small amount of cash on hand and keep it in a pocket.

        L.   Security violations should be reported as follows:

             1.   Immediate threat: Call the operator to report the incident. She will call Security.

             3.   No immediate threat:

                  a.   Notify supervisor
                  b.   Fill out an occurrence report.

II.     REFERENCE.

        A. Russell County Hospital Environment of Care Plan, 2001.

        B. Laboratory Compliance Insider newsletter, August 2005, pp. 6-7.




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