Desert Pacific Healthcare Network (VISN 22)

Issue: It was reported that Patient medical records were lost due to inappropriate handling by UPS. Update: 10/02/12:One Veteran will be sent a letter offering credit protection services.…

Outcome: UPS offered to reimburse for the cost of the credit monitoring cost and the pages printed. This was a error on UPS.…

Issue: On 09/11/12, someone dropped off a total of 18 plastic bags with patients' personally identifiable information (PII) on label adhesives in the alternate Privacy Officer's (PO) office. This person did not leave contact information and details. The labels contained patients'…

Outcome: Privacy Officer will provide education and training to employees during privacy and environmental rounds.

Issue: The ISO received phone call from Mandalay Bay Casino employee who stated she received a document by mistake, and agreed to destroy the document. Upon investigation the Pharmacist faxed the document to a nursing home regarding renewal of medication for…

Outcome: The Pharmacist faxed the medication order request to the Nevada Veterans Nursing Home using the speed dial function on the fax machine. The fax was received by the Mandalay Bay Casino by mistake, who upon receiving the misdirected fax notified…

Issue: A Veteran reported that while undertaking a liver biopsy with a VA Contractor Steinberg Diagnostic (VISN contract), a contracted nurse shouted out "I gave the HIV patient...his shot" in a room with other patients. Update: 09/12/12:One Veteran will be sent…

Outcome: Contractor nurse did make the statement about giving the HIV patient his shot; however she claims she was speaking about the other patient and not the VA Veteran, this could not be confirmed. Regardless who she was speaking about, Veteran…

Issue: An employee printed Title 38 7332 information to assist in Human Resources (HR) personnel action. The evidence file presented contained medical information of seven different patients. The employee removed the medical information from the facility and kept it in custody…

Outcome: Employee has been sanctioned and re-educated. Recommend this incident to be closed. No notification is required. Awaiting promotion codes.…

Issue: A Clerk mailing letters to patients used an incorrect address label which contained the name, social security number, and date of birth of Veterans. No physical address was on the label and the letters were returned by the US Postal…

Outcome: User was contacted and counseled. User is aware of the policy and assures us that it was a onetime slip.…

Issue: A Human Resources Management Service (HRMS) Program Specialist mistakenly sent an email addressed to two employees on the same email informing them that their resumes have been referred for consideration for a vacancy. Not only did both employees know the…

Outcome: This is not the normal method of employee notification when their resumes are forwarded for consideration. Employee was educated by Privacy Officer, reminded to follow proper privacy protocols for notification. CM and notification letters uploaded and mailed on 8/3/12.…

Issue: On 08/01/12, a VA Long Beach Healthcare System (VALBHS) Licensed Vocational Nurse (LVN) from Primary Care/Specialty Care placed a roster containing 20 Veterans full names, social security numbers and phone numbers in an unsecured desk drawer prior to leaving for…

Outcome: Person responsible for not properly safeguarding PIIand PHI has been re-educated on the importance of safe guarding PII/PHI.

Issue: A VA Social Worker disclosed that a Veterans uses illicit drugs to the Department of Children and Family Services (DCFS). Update: 07/16/12:This was a State reporting to DCFS in accordance with a standing letter. Other medical information was also released…

Outcome: A notification letter was mailed to the Veteran on 12-17-12. The supervisor of the emplyoyee was aware of the inappropriate disclosure and educated the employee on the legal, proper procedures for disclosing this type of information.

Issue: Veteran A received Veteran B medication bottle included in Veteran A mailed package. PII included full name and medication type. Update: 07/13/12:Veteran B will be sent a notification letter.…

Outcome: Employees reminded to verify correct Veteran prior to dispensing medications, plus for discussion at Staff Meeting. Notification letter uploaded and mailed on July 13, 2012.…