What steps should be taken when a breach of Protected Health Information is suspected?

by | May 19, 2023 | HIPAA News and Advice

When a breach of Protected Health Information (PHI) is suspected, the following steps should be taken: immediately investigate the incident to determine the scope and nature of the breach, mitigate any ongoing risks, contain the breach, if possible, notify the affected individuals and relevant regulatory authorities as required by law, document the breach and response actions taken, conduct a risk assessment, implement measures to prevent future breaches, and provide training and awareness programs to staff to ensure compliance with PHI security and privacy regulations. Healthcare professionals, especially those entrusted with managing PHI, must be well-versed in the appropriate steps to take when such a breach is suspected.

Immediate Assessment and InvestigationCreate a response team to assess and investigate the suspected breach promptly.
ContainmentTake immediate steps to halt further unauthorized access or disclosure of PHI.
Notification of Affected IndividualsIf the breach is confirmed, promptly notify the affected individuals, providing details of the breach and steps being taken to mitigate harm.
Notification of Regulatory AuthoritiesComply with relevant laws and report the breach to regulatory authorities as required.
Documentation and Record-keepingMaintain thorough documentation of the breach and all response actions for legal and compliance purposes.
Risk AssessmentConduct a risk assessment to evaluate potential harm and inform further actions.
Mitigation MeasuresImplement measures to mitigate harm, such as credit monitoring for affected individuals or enhanced security controls.
Preventive MeasuresReview and enhance security policies, conduct employee training, and assess and update security measures to prevent future breaches.
Legal ConsiderationsEngage legal counsel to ensure compliance with laws and regulations and address potential liabilities.
Communication StrategyDevelop a clear and transparent communication strategy for affected individuals, regulatory authorities, and the public if necessary.
Monitoring and AuditingContinuously monitor and audit security measures to ensure ongoing effectiveness and compliance.
Training and EducationProvide regular training and education to staff on PHI security and breach response protocols.
Review and Update PoliciesPeriodically review and update PHI security and breach response policies to align with industry best practices.
Engage Cybersecurity ExpertsConsider involving cybersecurity experts to conduct forensic analysis and enhance security.
Audit Trails and Access LogsMaintain audit trails and access logs for systems containing PHI.
Notification to Business AssociatesNotify business associates or third-party vendors with access to PHI if they are involved in the breach.
Follow State LawsBe aware of and comply with state-specific breach notification laws in addition to federal regulations.
Table: Steps to Follow When a Breach of PHI is Suspected

The initial step when a breach of PHI is suspected is to immediately start an assessment and investigation. This involves assembling a dedicated response team, which may include privacy officers, security experts, legal counsel, and IT professionals. The team’s primary objective is to determine the scope and nature of the breach. They should act swiftly to minimize further exposure or damage. Once the breach is confirmed, containment becomes necessary. This involves taking measures to stop the unauthorized access or disclosure of PHI. Depending on the situation, this may require isolating affected systems, revoking access credentials, or terminating the source of the breach.

Federal and state laws require the notification of affected individuals in the event of a PHI breach. This notification should be made as soon as possible and in compliance with the legal requirements of the relevant jurisdiction. It must include a detailed description of the breach, the types of information compromised, and the steps being taken to mitigate harm. Alongside notifying affected individuals, certain breaches may necessitate reporting to regulatory authorities. The specific reporting requirements depend on the nature and scale of the breach, as well as the applicable laws. HIPAA in the United States, for example, requires the reporting of breaches affecting 500 or more individuals to the U.S. Department of Health and Human Services (HHS) and the media. If the breach involves a business associate or third-party vendor with access to PHI, healthcare organizations must promptly notify them. Business associate agreements should outline the responsibilities and obligations of these parties in the event of a breach.

It is necessary to maintain documentation of the breach and all response actions taken. This documentation should include incident reports, investigation findings, communication records with affected parties, and any steps taken to prevent further breaches. A risk assessment should be conducted to evaluate the potential harm resulting from the breach. This assessment considers factors such as the nature of the compromised data, the number of individuals affected, the extent of unauthorized access, and the likelihood of data misuse. The results of the risk assessment inform subsequent actions.

To mitigate potential harm, healthcare organizations must implement appropriate measures. This may include offering credit monitoring services to affected individuals, changing access controls, enhancing encryption, or implementing additional security measures to prevent future breaches. Beyond immediate mitigation, healthcare organizations should take steps to prevent future breaches. This involves reviewing and enhancing security policies and procedures, conducting employee training and awareness programs, and regularly assessing and updating security measures in response to evolving threats. Healthcare professionals and staff should receive regular training and education on PHI security and privacy protocols. This includes understanding the importance of safeguarding PHI, recognizing potential security threats, and knowing how to respond in the event of a breach.

It is important to engage legal counsel throughout the breach response process. Legal experts can provide guidance on compliance with HIPAA laws, regulations, and reporting requirements. They can also offer advice on potential liability and legal actions that may arise from the breach. Depending on the severity of the breach, engaging cybersecurity experts may also be necessary to conduct forensic analysis, identify vulnerabilities, and strengthen the overall security posture. Healthcare entities must also be aware of and adhere to state-specific breach notification laws, which may have different thresholds and requirements.

Crafting a well-thought-out communication strategy is necessary during a PHI breach. Healthcare organizations should maintain transparency with affected individuals, regulatory authorities, and the public if necessary. Consistent and accurate messaging can help mitigate reputational damage. Continuous monitoring and auditing of security measures are important. This ongoing oversight ensures that the implemented measures remain effective and compliant with evolving regulations and threats. Organizations should maintain audit trails and access logs for all systems containing PHI. These logs can be invaluable during breach investigations, helping to pinpoint when and how the breach occurred. Healthcare organizations should periodically review and update their policies and procedures regarding PHI security and breach response. This ensures that their protocols remain current and aligned with industry best practices.


A suspected breach of PHI demands a systematic response from healthcare professionals. The steps mentioned provide a framework to address such incidents effectively while ensuring compliance with legal obligations and the preservation of patient privacy. Acting promptly, decisively, and transparently is required to maintain the trust and integrity of healthcare organizations.


What is HIPAA Protected Health Information and why is it significant?
What are examples of protected health information?
How does HIPAA PHI differ from other types of patient data?
What is protected health information under HIPAA?
How long should an individual retain protected health information (PHI)?
What are the primary risks associated with mishandling Protected Health Information?
How can healthcare organizations safeguard HIPAA Protected Health Information effectively?
Are there specific software solutions designed to protect HIPAA PHI?
How does the digital storage of records impact the security of Protected Health Information?
Which personnel within a healthcare facility have access to HIPAA Protected Health Information?
What are the legal consequences of leaking HIPAA PHI unintentionally?
How does encryption technology help in protecting HIPAA Protected Health Information?
Can patients themselves request access to their own HIPAA PHI?
How frequently should healthcare providers audit their storage of Protected Health Information?
What role do third-party vendors play in ensuring the safety of HIPAA PHI?
How do healthcare mergers impact the management of HIPAA Protected Health Information?
Are there guidelines on how to physically store documents containing HIPAA PHI securely?
How has the cloud computing revolution affected the storage of HIPAA Protected Health Information?
How are breaches of HIPAA PHI typically discovered and reported?
What educational initiatives exist for healthcare professionals about Protected Health Information?
How do mobile devices and apps ensure they don’t breach HIPAA Protected Health Information standards?
What are the ethical implications of mishandling HIPAA PHI?
How do international healthcare facilities handle HIPAA Protected Health Information?
What challenges do small private practices face in safeguarding HIPAA PHI?
How do medical research entities handle and protect HIPAA Protected Health Information?
Can unauthorized sharing of HIPAA PHI on social media lead to legal actions?
How does biometric data collection align with HIPAA Protected Health Information standards?
What steps should be taken when a breach of Protected Health Information is suspected?
How do patients get notified if their HIPAA PHI has been compromised?
Are there any certifications for software platforms handling HIPAA Protected Health Information?
What is the role of the Office for Civil Rights concerning HIPAA PHI breaches?
How do state-specific laws impact the handling of HIPAA Protected Health Information?
How do telehealth services ensure the confidentiality of HIPAA PHI during sessions?
Can wearable health devices compromise the security of HIPAA Protected Health Information?
How can patients ensure that their HIPAA PHI is being stored and managed correctly?
What are the implications for insurance providers regarding breaches of HIPAA Protected Health Information?
Can healthcare organizations use HIPAA PHI for marketing purposes?
How can whistleblowers report potential misuse of HIPAA Protected Health Information?
What considerations do pharmaceutical companies have to make regarding HIPAA PHI?
How do HIPAA PHI regulations impact health tech startups?
Are there specific protocols for destroying outdated HIPAA Protected Health Information?
Can data analytics on patient data be performed without breaching HIPAA PHI guidelines?
How do patients’ genetic data get protected under HIPAA Protected Health Information guidelines?
How do hospitals integrate new technologies without risking HIPAA PHI security?
Are there challenges in cross-border transfer of HIPAA Protected Health Information?
How do patients provide consent for the use of their Protected Health Information in research?
What role do firewalls and VPNs play in safeguarding HIPAA PHI in hospitals?
Can mental health records have different regulations under HIPAA Protected Health Information standards?
What initiatives can increase transparency in the handling of HIPAA PHI by healthcare institutions?
3 Steps To HIPAA Compliance

Step 1 : Download Checklist.

Step 2 : Review Your Business

Step 3 : Get Compliant!

Our HIPAA compliance checklist will outline everything your organization needs to become fully HIPAA compliant. Fill in the form below to download it now.

View our privacy policy