Minneapolis VA Health Care System

Issue: A VA employee inappropriately accessed a deceased Veteran's medical record because of a news media event.

Outcome: 09/29/14: The Incident Resolution Service Team has determined that the Veteran's Next of Kin will be sent a notification letter.…

Issue: A Root Cause Analysis folder turned up missing. Unable to locate.

Outcome: 09/25/14: The Incident Resolution Service Team has determined that four Veterans will be sent a letter offering credit protection services.…

Issue: Former VA supervisor called a retired VA employee and claimed she knew about his health problems from another VA supervisor.

Outcome: 09/15/14: The Incident Resolution Service Team has determined that Individual A will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed. 09/16/14: Per the PO - After doing an audit on access to the record…

Issue: A Contract Community Based Outpatient Clinic (CBOC) mailed a letter to a patient and printed a name, SSN, and DOB label on the envelope. The USPS returned it to clinic due to insufficient address.

Outcome: 08/27/14: The protected health information was on the outside of the envelope although it was returned by the USPS for insufficient address. Since the information was only seen by the USPS in the performance of their duties, the risk of…

Issue: A travel pay form was mailed to a Veteran. Attached to the back was a list of 6 other Veterans to receive travel pay forms. The form contained the other Veterans' names, dates of birth, and full SSNs.…

Outcome: 08/27/14: The Incident Resolution Service Team detemined that the 6 Veterans will receive a letter offering credit protection services, since their full SSNs were compromised.…

Issue: A travel pay form was mailed to a Veteran, attached to the back was a list of Veterans to receive travel pay forms.

Outcome: 08/12/14: The Incident Resolution Service Team has determined that seven Veterans will be sent letters offering credit protection services.…

Issue: Employee complaint that previous supervisor lost employee records pertaining to her.

Outcome: 07/24/14: The Incident Resolution Service Team has determined the employee will be sent a letter offering credit protection services, as her documents containing full SSN have been lost.…

Issue: A Veteran found Radiology consults folded and left in a magazine in the Radiology waiting area. He turned them in to the front desk.

Outcome: 06/25/14: The Incident Resolution Service Team has determined that three Veterans will be sent letters offering credit protection services.…

Issue: Veteran was provided the wrong prescription at the pharmacy outpatient window.

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: Generic letters were sent to Veterans informing them of a new Community Based Outpatient Clinic (CBOC) opening. One batch of letters were duplexed and sent, resulting in letters sent to Veterans with another Veterans letter containing full name and address…

Outcome: 06/03/14: It was a batch of 1000 letters, 500 of which received a letter with the duplicated letter on the back side. The Director of Medical Media is trying to determine which 500 did not receive a "CBOC Grand Opening"…