Clement J. Zablocki Veterans Affairs Medical Center

Issue: An employee mailed two Patients' medical records to the same recipient. A self-addressed postage-paid envelope is being sent to the incorrect recipient so that he/she may return documentation at VHA expense.

Outcome: 05/28/14: The Incident Resolution Team has determined that one Patient will be sent a letter offering credit protection services due to full SSN being disclosed.…

Issue: Two lab letters, sent individually by same VHA PACT team, were sent to the incorrect recipients along with the correct info. Incorrect Patient A's info included full name, address, lab result, and full SSN. Incorrect Patient B's info included full…

Outcome: 05/27/14: The Incident Resolution Team has determined that Patient A will be sent a letter offering credit protection services due to full SSN being disclosed, and Patient B will be sent a HIPAA notification letter due to Protected Health Information…

Issue: Four (4) completed 1010EZ's were accidentally faxed by VHA Employee to private company. Company reports shredding the documentation, but it is unclear at this time to what extent. If retrievable, will request that info is mailed back to VHA facility…

Outcome: 05/22/14: The Incident Resolution Team has determined that four Individuals will be sent letters offering credit protection services. plus 2 spouses information was disclorsed. 06/17/14: On Veteran can not be located, as "Return to Sender, Insufficient Address, Unable to Forward."…

Issue: A series of medications were mislabeled by a VHA employee and sent to incorrect patients. In comparison to the other three tickets from this facility, recently, of the same nature, this is a consolidated ticket for 13 patients whose medications…

Outcome: 05/15/14: HIPAA notifications will be sent to 13 patients.…

Issue: A VHA employee placed duplicate labels onto additional medication packages. As a result, Patient A received Patient B and C's medications in addition to his own, with enclosures. Patient A has since returned Patient B and C's medications, and said…

Outcome: 05/15/14: The Incident Resolution Team determined that Veterans B and C will receive HIPAA letters of notification since their protected health information (PHI) was disclosed..…

Issue: A VHA employee applied duplicate labels on two medications before mailing out. As a result, Patient A received Patient B and C's medications and enclosures. Patient A returned prescriptions to the VHA Pharmacy to trade for the correct prescriptions.

Outcome: 05/15/14: The Incident Resolution Team determined that Veterans B and C will receive HIPAA letters of notification since their protected health information (PHI) was disclosed.…

Issue: Patient A was mailed Patient B's medication. Medication has been returned by Patient A.

Outcome: 05/09/14: The Incident Resolution Team has determined that Patient B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Patient A received both Patient A's medication and Patient B's medication. Patient A will be returning Patient B's medication for destruction.

Outcome: 05/09/14: The Incident Resolution Team has determined that Patient B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: A Release of Information (ROI) employee released two Patients' medical records to the same location as a clerical error on 04/25/14. This was reported by receiving attorney of correct Patient A, who will return (today) Patient B's information to the…

Outcome: 05/07/14: The Incident Resolution Team determined that Patient B will receive a letter offering credit protection services, since his name and date of birth was compromised.…

Issue: VA Primary Care staff has notified Privacy Office that daughter of VA Employee was seen transporting Veteran death certificates to various locations in the facility. The death certificates were in manila folders, not bound from access by the non-Volunteer, non-Employee…

Outcome: 05/14/14: The PO reports that one Veteran's information was potentially compromised by the employee's daughter. The Incident Resolution Team has determined that the Veteran's Next of Kin will be sent a notification letter.…