Louis Stokes Cleveland VA Medical Center

Issue: Veteran A hand delivered Veteran B's medical records he received to the clinic. Both patients had gone to the ROI department for copies of records and the wrong records were mailed. All pages have been returned.

Outcome: 08/06/14: The Incident Resolution Service Team has determined that Veteran B will be sent a letter offering credit protection services, as his full SSN was disclosed.…

Issue: Employee accessed the medical record of an employee/patient. Employee/patient stated that they do not believe the employee had a need to know to access their medical record.

Outcome: 08/27/14: The employee did not have need to know to access the Veteran/employee's medical record. The Incident Resolution Service Team determined that the Veteran/employee will receive a HIPAA letter of notification.…

Issue: Nurse reported that they accidentally gave a patient A another patient's (patient B) discharge instructions. Patient left before they could recover, patient called on 7-25-14. The dc instruction included name and meds but no SSN or DOB.

Outcome: 07/25/14: The Incident Resolution Service Team has determined that Patient B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Patient received six appointment reminders on other patients. Patient returned the six letters to the CBOC administrator today. Appears it may be a bulk issue error.

Outcome: 07/17/14: The Incident Resolution Service Team has determined that six Veterans will be sent a notification letter.…

Issue: A VA Social Worker believes a VA Employee disclosed medical records to an ex-spouse and mother of a Veteran without the Veteran's authorization. These were paper records, including the Veteran's name, address, full SSN, date of birth and protected health…

Outcome: 07/18/14: The Privacy Officer (PO) spoke with the Employee. He stated the next of kin (NOK) told him the Veteran was a patient in the hospital. The NOK was listed on the Power of Attorney (POA), however the Veteran was…

Issue: The Administrative Officer of the Day (AOD) found an appointment list containing 31 patient names, cell phone, diagnosis and date/time of appointment in the Atrium of the Medical Center. It appears an employee left it on a table. The Weekend…

Outcome: 07/07/14: The report was printed on Friday, so it could have been possibly out in the atrium from Friday 8 AM until Saturday Morning 8:30 AM when the employee saw and secured it. The Privacy Officer will be interviewing two…

Issue: A VA employee sent an unencrypted email containing the Request Pertaining to Military Records Form. The form contained Veteran B's information. The clerk thought the form was blank and gave it to Veteran A. Veteran A returned the completed form…

Outcome: 06/06/14: The Incident Resolution Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: A Veteran brought down a Travel Reimbursement form on another Veteran that was accidentally included in his information. It was a one page form. Included patient name, last 4 of ssn, home address and appointment date. The Veteran returned the…

Outcome: 06/03/14: The Incident Resolution Team has determined that one Veteran will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: A clerk gave a medication list for Patient A to Patient B.

Outcome: 05/28/14: Patient A will receive a HIPAA letter of notification since his protected health information (PHI) was disclosed.…

Issue: A Social Worker left a Clinic Appointment Listing in a restroom. Once the Social Worker noticed the document was missing she returned to the restroom, however the document was not there.

Outcome: 06/02/14: The Incident Resolution Team has determined that nine (9) Veterans will be sent a notification letter.…