Patient Safety

Fall Reduction

Upon admission and during every shift nursing staff assess acute care patients using a fall scale that rates the patient’s gait, transferring ability, need for ambulatory aid, mental status, recent fall history and whether IV or other lines are present. All critical care patients are automatically classified as high-risk.

Interventions should be based on the scale results, as well as individualized to the patient. Physicians should consider the need for assistive devices, a change in medications, orders for physical therapy or other orders that can reduce fall risk.

Medical Staff Privacy and Security Sanctions

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires protection of confidential information contained within a healthcare information system. Inappropriate access, use, and/or disclosure of PHI may result in the imposition of fines up to $1,500,000 and subsequent felonious fines to include imprisonment, according to the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH).

A member of the medical staff and/or their staff is in violation of this policy if he/she inappropriately accesses any record other than the records assigned to him/her as attending or referring physician.

Examples of inappropriate access include but are not limited to accessing one’s own record, a family member’s record, a friend’s record, or a co-worker’s record. When members of the medical staff and/or their staff are granted access to PHI in electronic form, assigned user names, passwords, and access codes shall be protected. These codes should not be revealed to anyone or recorded where they may be viewed by another.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires protection of confidential information contained within a healthcare information system. Inappropriate access, use, and/or disclosure of PHI may result in the imposition of fines up to $1,500,000 and subsequent felonious fines to include imprisonment, according to the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH).

Members of the medical staff and their staff who have access to protected health information are required to sign the Information Systems Security Acknowledgement and Nondisclosure Agreement.

Alleged patient information privacy or security violations will be thoroughly investigated by the privacy/security officer and appropriate action will be taken to maintain the privacy of the patient.

Sanctions for privacy or security violations include:

The following is a listing of progressive disciplinary actions:

Patient privacy (HIPAA)

All healthcare providers are obligated to take reasonable safeguards to protect patient privacy. HIPAA (Health Insurance Portability and Accountability Act) regulations govern providers’ use and disclosure of health information, and grant patients rights of access and control. They also establish civil and criminal penalties for violations of patient privacy. Fines range from $100 to $50,000 for each episode. When privacy violations occur, disciplinary actions will be taken.

Healthcare providers’ obligation to protect patient health information includes all formats: written, electronic and oral communication. Protected Health Information (PHI) may not be discussed in front of a patient’s family, friends, and/ or visitors without the patient’s permission. You should ask individuals to momentarily leave a patient’s room while you discuss the patient’s health information/condition with the patient.

There are two exceptions to this portion of the rule: professional judgment and emergency situations. Other situations when you should be especially aware of protecting verbal disclosures occur with reports, educating students, voice messages, telephone conversations discussions in waiting rooms or semiprivate rooms. When discussing health information with another provider or the patient use reasonable safeguards to prevent others from overhearing.

Physicians may only access, use or disclose protected health information when they have a legitimate need to know in order to perform their job function, regardless of the extent of access provided to them. The phone number for St. Dominic’s HIPAA Privacy Office is 601-200-6978.

Password Protection

All passwords to information are confidential. Under the Mississippi Code 1972: Sec 97-45-5, it is a computer crime to use another person’s password or disclose passwords to another for the purpose of obtaining unauthorized access to computers. Do not give your staff including your nurse practitioner and nurses your individual portal log-in and password.

Patient Identification

Prior to administering tests, treatments, medications, or procedures, at least two patient identifiers on the patient’s armband are matched to the same patient identifiers on another document, item, or hand-held device or screen that is also in the immediate presence of the patient.

The patient’s armband must be legible and on the patient. The required two identifiers are: patients first and last name and the patient’s account number.

Unacceptable Abbreviations


 Unacceptable  Correct       
 I.U. Or IU (for international unit)  Write “international unit”
 U or u (for unit)  Write “unit”
 Q.D., QD (Latin abbreviation for daily)  Write “daily”
 Q.O.D or QOD (Latin abbreviation for every other day)  Write “every other day”
 MgSO4  Write “magnesium sulfate”
 MS or MSO4  Write “morphine sulfate”
 Leading decimal (.5 mg)  0.5 mg
 Trailing zero (1.0 mg)  1 mg


Unclear or incomplete medication orders including unapproved abbreviations are clarified with the physicians as soon as possible and the clarified order is signed within 24 hours. Medications should not be dispensed or vended until the order is clarified in the medical record; however a single dose of medication may be dispensed in cases where delay would result in patient harm.

Blood transfusions

All orders to transfuse a blood product require completion of the preprinted order form. It is available at all the nursing stations and the operating room.

Follow these steps to complete the form:

Remember: Transfusions require informed consent. For more information, please refer to the Reference Manual located on Dominet.

Medical Emergency/Codes

Emergency extensions are as follows:

 South Campus:  
 Building Utilities  601-200-6909
 Repair and Maintenance  601-200-6396
 Security Dispatch  0 (on campus)
 Cardiac Arrest (Code 99)  6999
 Equipment Repair  601-200-6785
 Fire (Doctor Red)  6999
 Medical Emergency  6999
 Safety/Risk Management Office  601-200-6989
 Structural Failure  601-200-6909
 Emergency Preparedness Coordinator  601-200-5863, pager 1650
 Disaster Control (ER Desk)  601-200-6174



 North Campus:  
 Maintenance  601-200-3196
 Medical Emergency  601-200-3999
 Housekeeping  601-200-3148



Emergency Codes

The emergency codes are as follows:

 Code  Emergency
 Code 446  Civil Disturbances
 Code 99  Cardiac/Respiratory Arrest
 Code Adam  Infant Abduction
 Doctor Red  Fire
 PERT  Patient Evaluation Response Team


To report an emergency code, dial campus emergency number and give location and nature of emergency.

Code 99

Code 99 indicates that there is a person (patient, employee, or visitor) in medical distress that needs the immediate attention of the code team.

If you are on the South Campus, dial 6999. Tell the operator that you have a “Code 99” to report and the location of the medical emergency (the department, floor number, room number or exact location).

For emergencies occurring outside of the hospital such as the parking garage security can be contacted by calling 601- 200-8911.

Patient Evaluation Response Team (PERT)

St. Dominic’s rapid response team is called PERT (Patient Evaluation Response Team). When any member of the patient’s care team has reason to suspect that a patient on a regular unit, (not in a critical care unit) is experiencing an unanticipated change in condition, a PERT may be called to assist the primary caregiver. The PERT can provide the nurse or clinician with an assessment by a critical care nurse and respiratory therapist in a supportive, collegial role.

The role of the PERT is to provide timely and in-depth assessment; to assist with communication; to stabilize, if possible; to implement approved orders; to educate and support staff; and to assist with transferring the patient to a different level or care, if necessary. For more information, please refer to the Reference Manual located on Dominet.

In Case of Fire: RACE

Patient Access Center (PAC)

Patients must meet medical necessity for the level of care you order. The patient access center is staffed 24/7 by RNs, utilizes one central phone number to call for making a bed reservation and to obtain the status of our beds.

Admitting your patient:

Step 1: Before calling, have the following information on hand:

Step 2: Call 601-200-2777

Step 3: We will assign a bed or provide information to you as to current bed availability and an appropriate time in which we can receive the patient.

Step 4: Fax orders and/or office notes along with other relevant documentation to 601-200-6671.

Restraint and Seclusion

A physician’s written order must be obtained for the use of restraint or seclusion. No PRN or standing orders are permitted. The order for restraint or seclusion must include start date and time, stop date and time, clinical justification for the restraint, type of restraint, early release criteria, physician signature with date and time.

The RN may initiate emergency use of restraint as long as an order for the restraint is obtained within one hour of initiation of the restraint.

An order for restraint must not exceed a twenty-four (24) hour period of time. If restraints are continued for greater than twenty-four (24) hours, the physician must perform a face to face in-person evaluation. A new or renewed order for restraint must be issued no less than once each calendar day.

Orders for restraint or seclusion must not exceed:

The patient in restraint/seclusion is evaluated frequently and the intervention is ended at the earliest possible time.

For more information, please refer to the Reference Manual on Dominet.

Continuing Medical Education (CME)

St. Dominic Hospital is accredited by the Mississippi State Medical Association to provide Continuing Medical Education (CME) for physicians.

St. Dominic’s takes responsibility for the content, quality and scientific integrity of the CME activity and designates each activity for a specific amount of AMA PRA Category 1 credit(s)TM Physicians Recognition Award. Records of CME attendance and credit hours are maintained in a database, and reports are distributed to physicians upon request. Each physician should claim only those credits that he/she actually spent in the activity. CME opportunities are available at by clicking on the link “CME”.

For more information, please contact the CME coordinator at extension 6686.

Disaster Response

St. Dominic Hospital’s Emergency Management Program is based on evaluations of community needs through hazard analysis and organizational experience.

In the event of a community disaster, communication regarding the disaster’s scope and the response of the Medical Staff must be timely. If you are in the hospital, at your office or home and become aware of a pending or an in-progress disaster impacting our community, you can acquire timely information and instructions by contacting the medical staff services at extension 6846.

Do not report directly to the Emergency Department unless you are instructed to do so. For more information see Emergency Management Plan under Documentation on Dominet.

Disruptive Physician Behavior/Professional Conduct

All practitioners will conduct themselves in a professional and amicable manner within St. Dominic’s facilities to ensure optimum patient, associate, medical staff, and visitor relations. A workplace where all are treated with dignity, respect, and hospitality is in harmony with St. Dominic’s missions and values.

By way of example, practitioners should:

For more information see Medical Staff Policies and the Professional Code of Conduct.

Physician Health and Well-Being

St. Dominic Hospital sponsors a Medical Staff Committee for Physician Health and Well-Being which consists of the chair and at least four medical staff members. The chairman of this committee is appointed by the chief of staff and members are appointed on an ad hoc basis that may include: distinguished senior members of the medical staff; a psychiatrist, a high risk area representative (anesthesiology, surgery, and emergency medicine) or others.

This committee addresses issues of practitioner health including the prevention of physical, psychiatric or emotional illness. It is responsible for facilitating confidential diagnosis, treatment and rehabilitation of practitioners who suffer from potentially impairing conditions. The committee focuses on assistance and rehabilitation, rather than discipline, to aid a practitioner in retaining or regaining optimal professional functioning, consistent with the protection of patients.

The committee will also consider general matters related to the health and well being of the medical staff and develop educational programs or related activities about illness and impairment recognition issues specific to medical staff members for the hospital staff and medical staff.

Please click here to access the Fact Sheet for Recognizing Physician Impairment.

Medical Staff Membership Obligations

Each physician appointed to the St. Dominic Hospital Medical Staff, regardless of medical staff category, have obligations listed in the Medical Staff Bylaws and shall:

a) Provide patients with continuous care at the generally recognized professional standard of quality, efficiency and safety and provide and continuously update a written attestation that he will provide continuous care for his/her patients including specific names, addresses and contact information for coverage if the practitioner is, for whatever reason, unavailable.

b) Seek appropriate consultation or refer to a practitioner who has expertise in cases outside the practitioner’s training and usual are of practice in accordance with Hospital policy, these Bylaws and Rules and Regulations.

c) Abide by the Medical Staff Bylaws and by all other lawful standards, policies and rules of the medical staff and hospital. Abide by practice guidelines and clinical pathways and other quality initiatives approved by the medical staff and the hospital.

d) Abide by all local, state and federal laws, rules and regulations.

e) Perform such medical staff, department, service and hospital functions for which he is responsible by staff category assignment, appointment or otherwise.

f) Prepare and complete all medical and other required records in a timely manner, for all patients he admits or patients for which he provides care while in the hospital.

g) Adhere to generally recognized standards of medical and professional ethics, insofar as they do not conflict with Catholic teachings (with regard to services provided at the Hospital), including (without limitation) prohibitions against fee-splitting, ghost surgery, improper delegation of responsibility for diagnosis or care of patients (such as to a practitioner not qualified for the responsibility), and failure to obtain informed patient consent to treatments.

h) Provide the same level of care for all patients receiving similar services, regardless of the location in the hospital in which the service is provided.

i) Participate in continuing education activities appropriate for his/her practice area.

j) Acknowledge that the hospital has the authority to develop various hospital and medical staff management plans and agree to request clinical privileges in a manner consistent with the hospital’s plans.

k) Abide by and require any APP under his/her supervision credentialed by and providing services at the hospital to abide by the Hospital’s Notice of Privacy Practices because the hospital and its medical staff are part of an organized heath care arrangement, as such is defined in the Standards for Privacy of Individually Identifiable Health Information Promulgated under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996. The sponsoring practitioner is liable for the patients seen by the APP(s). The organized medical staff and ultimately the board of directors are responsible for all treatment at the hospital.

l) Authorize the medical staff services department of the hospital to consult staff members and/or employees of other hospitals with which the applicant is or has been associated and any other person who may have information bearing on his/her professional conduct, competence, character, ability to perform the clinical privileges requested and ethical qualifications for medical staff membership.

m) Acknowledge that the hospital will access and gather information from the National Practitioner Data Bank and the U.S. Office of Inspector General Sanction Report and the General Services Administration Excluded Providers List from time to time during any applicable reappraisal process.

n) Practitioner shall provide information about any currently pending malpractice actions or final judgments or settlements of malpractices actions.

o) Participate in appropriate peer review activities including OPPE and FPPE consistent with appropriate conflict-of-interest consideration.