Clement J. Zablocki Veterans Affairs Medical Center

Issue: A prescription was mis-mailed to the incorrect patient. The prescription was turned back in by incorrect recipient.

Outcome: 04/18/14: The Incident Resolution Team has determined that the Veteran whose medication and date of birth were improperly disclosed will be sent a letter offering credit protection services.…

Issue: Patient A received copy of his lab results letter with combined information from Patient B on other side of paper. The information is from two different clinics (PC for Patient A, MH for Patient B). Does not appear to be…

Outcome: 04/01/14: The Incident Resolution Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: Patient A's daughter reported that while Patient A was on an inpatient ward, they were approached by Interventional Radio Physician to have daughter sign consent form for Patient B for a specified diagnosis. After refusing (daughter stated Patient A does…

Outcome: 03/18/14: 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: Pick-up log for contracted transport containing PHI and appt times with phone numbers blew out of van when both doors were open. Log was not retrieved.

Outcome: 03/13/14: Notification letters will be sent to eight Veterans.…

Issue: Up to two lab specimens that were being transported to contracted facility for completion did not arrive at their intended destination, via VHA Facilities Management courier. Specimens were found outside of contracted facility by member of public who brought one…

Outcome: 03/12/14: The Incident Resolution Team has determined that Veteran A will be sent a letter offering credit protection services.…

Issue: Patient A received a copy of her own Discharge instructions with Patient B's ID sticker placed on it, including full name, SSN, and DOB. Patient A returned the copy five days later, when seen again in clinic. Patient A's information…

Outcome: 02/20/14: Patient B will be sent a letter offering credit protection services.…

Issue: Patient B's information was inappropriately scanned into Patient A's medical record. As a result, Patient B's information was mistakenly released to Patient A's attorney upon request for date-range of records. The Privacy Officer spoke with the attorney, and no further…

Outcome: 02/10/14: Patient B will be sent a letter offering credit protection services.…

Issue: A Patient opted-out from inpatient directory, but spouse contacted one of the PC clinics and the Medical Support Assistant (MSA) disclosed ward location of Patient. Subsequently, the spouse has been repeatedly calling and harassing staff to get a hold of…

Outcome: 01/31/14: The patient will receive a HIPAA letter of notification.…

Issue: VHA Employee had charge pressed for having inappropriate relations with Veteran. After HR initiated actions, Employee employed an attorney to represent. Though correspondence from VHA to Employee referred to Veteran only by initial of last name, correspondence from Employee's attorney…

Outcome: 01/23/14: The Veteran will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Lab letter generated by PC for Patient A had another lab letter for Patient B stuck to back, and was folded and sealed automatically by Mail Room equipment. Patient A called to complain that she received two sets of results,…

Outcome: 12/19/13: Patient B will receive a HIPAA letter of notification.…