Desert Pacific Healthcare Network (VISN 22)

Issue: A Veteran claims a VA nurse left a voice mail on his home answering machine that identified what type of medication he was taking. The Veteran's family and spouse were not aware the Veteran was taking that specific medication and…

Outcome: The RN did leave a message on the machine that identified a specific medication the Veteran is taking, she stated she left the message that said his requested medication was not due for refill and therefore it could not be…

Issue: Veteran A received Veteran B authorization form via mail. Veteran A is also a VA staff provider. Update: 12/18/12:Veteran A will be sent a HIPAA notification letter.…

Outcome: Privacy Officer counseled employee on privacy protocol. Notification letter uploaded and mailed on December 21, 2012.…

Issue: A VA employee accessed several employee's record without authorization. One employee's record was accessed twenty-six times. A total of eleven employees' privacy was breached. Update: 12/14/12:Eleven (11) Employees will be sent letters offering credit protection services. Full SSN, medical information,…

Outcome: Investigation is still ongoing. Will report final outcome and corrective action within a week. 01/08/2013: The AIB has been completed. Access and controls are now in place. All staff has been re-educated on accessing eOPFs. Please close this ticket.

Issue: The Spokane VAMC Privacy Officer notified the VA Greater LA HCS Privacy Officer that a CDcontaining Veteran B's medical information was returned to her facility by Veteran A's wife. Update: 12/11/12:Veteran B will be sent a letter offering credit protection…

Outcome: The Chief of HIMS and the Release of Information Supervisor, have both been notified of the incident and the Privacy Officer requested an action from them. A Credit Monitoring Letter has been sent to the Veteran and a redacted letter…

Issue: Veteran A's daughter received Veteran B's health information and reported it to the Office of General Counsel in responding to a privacy complaint with the medical center. Veteran A is deceased. Update: 11/26/12:Veteran B will be sent a letter offering…

Outcome: The employee and his supervisor was notified of the mistake. The employee has been advised by the supervisor and privacy officer to check all outgoing mail prior to mailing it to confirm the contents and the address label. In addition,…

Issue: A Veteran Faxed a SF-5345a to Release Of Information (ROI) on October 17, 2012. A confirmation fax was received by the patient. ROI clerks have no record of the request. Update: 11/16/12:Due to full name an SSN being misplaced, Veteran…

Outcome: It has been determined after thorough investigation that the ROI request was inadvertently shredded by a VA employee.

Issue: Veteran A received Veteran B medication package. PII included name, address and type of medication. Update: 11/13/12:Veteran B will be sent a notification letter due to PHI being exposed.…

Outcome: Supervisor counseled employee and sent out reminder to all staff. Notification letter uploaded and mailed on November 14, 2012.…

Issue: Veteran A received Veteran B medication package, via mail. Names were identical, employee failed to check the last 4 SSN to ensure correct Veteran. PII included name, address and type of medication. Update: 11/05/12:Veteran B will be sent a notification…

Outcome: Unable to determine specific employee who mailed the medication without checking social security number as the First, Last and middle initial were identical. All employees reminded to check social security number, especially for common names. Notification letter uploaded and mailed…

Issue: Veteran A received Veteran B's medication via mail. The personally identifiable information (PII) included name, address, and type of medication. Update: 10/31/12:Veteran B will receive a HIPAA letter of notification.…

Outcome: Unable to determine which Pharmacist mis-mailed. Chief of Pharmacy is investigating the large number of mis-mailed medication lately to see if procedures need to change to prevent this in future. Staff reminded to double check prior to mailing. Notification letter…

Issue: Veteran A received Veteran B medication package to include the Prescription bottle and accompanied paperwork. PII included name, address and type of medication. Update: 10/29/12:Veteran B will be sent a notification letter.…

Outcome: Unable to determine which Pharmacist mis-mailed. Chief of Pharmacy is investigating the large number of mis-mailed medication lately to see if procedures need to change to prevent this in future. Staff reminded to double check prior to mailing. Notification letter…