Desert Pacific Healthcare Network (VISN 22)

Issue: On 04/14/2011, a VA Canteen Supervisor found a 1 page appointment list and 3 pages of medication informational profile in the canteen. The list was given to the Alternative Privacy Officer (PO) on the same day. The list contains one…

Outcome: Privacy Officer sent a Equifax letter to the Veteran on 4/25/11. Preventative measure are being taken to stop this from re-occurring.…

Issue: On 04/13/11, Patient A went to the lab to have work done and a VA employee discovered the ID card that Patient A had actually belonged to Patient B. It was determined that the cards were mixed up during the…

Outcome: Unable to determine which employee mixed up the ID cards; all employees in department reminded to be careful when giving back ID cards. Credit Monitoring letters mailed 4/18/11.…

Issue: On 04/08/11, the Canteen Supervisor found an appointment list in the Canteen. The list was given to the Alternative Privacy Officer on the same day. The list contains one Veterans full name and SSN and appointment time/location. The list was…

Outcome: All staff were briefed of the incident and reminded of the importance of protecting patient information. Privacy Officer sent out a Postmaster to all hospital staff re: safeguard of patient protected health information".…

Issue: The Privacy Officer (PO) received an email from the Health Resource Center (HRC) stating that a billing statement was mismailed to the City of San Luis Obispo employee who called and returned the information to the HRC. The email stated…

Outcome: The Veteran's address has been confirmed and updated. This was no fault of VA.

Issue: Patient A received Patient B fee basis authorization. Personally Identifiable Information (PII) included full name, last 4 SSN, and reason for referral (health information). Patient A agreed to shred the authorization form. Update: 03/08/11:Patient B will receive a letter of…

Outcome: Unable to determine which fee basis clerk mailed the wrong authorization out, so all employees reminded to be careful while mailing paperwork to Veterans. Notification letter mailed on April 11, 2011.…

Issue: An individual found a handwritten note in hallway. The handwritten note was given to Compliance Officer. The note contained patient's name, date of birth, son's telephone number, medication needed and need for consultation. The Compliance Officer went to the department…

Outcome: The Chief of nephrology met with his employees and discussed the lost note card and the importance of protecting materials with personal identifiers as well as distributed a memo with the HIPAA privacy Do's and Donts. A credit monitoring letter…

Issue: One Release of Information Staff mailed Veteran As medical record to Veteran Bs home. Veteran B returned all of Veteran As medical record to Release of Information Unit on April 1, 2011. Update: 04/04/11:Due to full SSN and medical information…

Outcome: Privacy Officer sent out the credit monitoring letter to Veteran B on 4/6/11. Re-training and education is provided to the Release of Information clerk. Appropriate action will be taken by the Supervisor and Human Resource Office.…

Issue: Patient A received Patient B's VistA Patient Inquiry page. Patient A refused to give back the document to the Patient Advocate or mail it back to VA, however has agreed to bring the document to the Privacy Officer on March…

Outcome: Credit monitoring letter mailed March 16, 2011 and uploaded. Supervisor counseled employee on maintaining privacy protocols and completed VA Privacy and Information Security Awareness and Rules of Behavior and VHA Privacy Policy Web Training.…

Issue: On 03/08/11, VBA Reno (Las Vegas Office) requested a follow up on two active duty medical records but staff in the Compensation & Pension Office sent the records back to VBA Las Vegas Office via UPS on 01/27/11. VBA states…

Outcome: UPS conducted an investigation to no avail, package containing the medical records were not located and UPS closed tracking ticket. Credit monitoring letters mailed 3/17/11.…

Issue: One of the Operating Room (OR) staff handed OR nurse manager a patient specimen sticker that was found on 2-28-11 by the 5th floor elevator in building 126. Update: 03/07/11:The label included the patient's full name, full social security number,…

Outcome: Service Chief sent announcement to all OR staff. Credit monitoring letter sent to the Veteran.…