New Mexico VA Health Care System

Issue: Respiratory therapist reported that ventilator flow sheet was missing from clipboard outside patient's room. Sheet contains patient information (name, partial SSN; DOB, and patient health information respiratory status/ventilator settings, and medication information. Initial search did not find the missing flow…

Outcome: 01/08/15: The Incident Resolution Service Team has determined that Veteran A will be sent a notification letter.…

Issue: The Outpatient Pharmacy Supervisor reported to facility Privacy Officer (PO) that Veteran A had not received a mailed prescription. Upon review of the shipping information, it was determined that Veteran B had received and signed for two prescriptions, even though…

Outcome: 12/10/14: The Incident Resolution Service Team has determined that Veteran A will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Veteran A reported to the facility Privacy Officer (PO) that he had received a copy of a faxed list included with his personal photocopied health information which had been mailed to his house. The faxed list was returned by Veteran…

Outcome: 12/08/14: The Incident Resolution Service Team has determined that four Veterans will be sent a notification letter.…

Issue: Chief Cardiology Resident reported to facility Privacy Officer (PO) that he was just made aware of privacy issue/loss as follows: On or about 10/24/14, a third year cardiology fellow was presented with the ECGs. They were contained in a manila…

Outcome: 10/30/14: These ECGs were not pulled or created from a list. They were randomly chosen for teaching/clinical relevance and placed in folder which was for use by residents/fellows as examples of specific types of tracings/indicators. In clarifying the situation with…

Issue: Two Veterans reported to facility Privacy Officer that information they had received in mail yesterday was mixed up; Veteran A received Veteran B information in his envelope; Veteran B not sure but did not receive entire packet of medical record…

Outcome: 10/22/14: The Incident Resolution Service Team has determined that Veteran B will be sent a letter offering credit protection services. It was confirmed that Veteran A's information was not sent to Veteran B.…

Issue: Privacy Officer was informed by Supervisor for Homeless Program on 10/15/2014 per advice from Human Resources Specialist handling HR action on responsible employee - that she needed to report a privacy violation. Supervisory Social Worker provided following details to Privacy…

Outcome: 10/28/14: The Incident Resolution Service Team has determined that Veteran A will be sent a letter offering credit protection services. 10/29/14: There were 21 Veterans' information in the box. Of those, 19 will be offered credit protection services and two…

Issue: The Information Security Officer (ISO) reported and provided initial audit log access investigation in regards to an inappropriate employee access to a fellow employee's record and ensuing Supervisor's fact-finding response. Privacy policy violation determined as employee who accessed fellow employee's…

Outcome: 10/17/14: The Incident Resolution Service Team has determined that the employee will be sent a notification letter.…

Issue: Medication was mailed to the wrong Veteran. The envelope was returned and it was confirmed that the mail clerk put the wrong label onto the package.…

Outcome: 10/15/14: The Incident Resolution Service Team has determined that Veteran B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Veteran A provided compensation and pension (C&P) documents to the Community Based Outpatient Clinic (CBOC) that were mailed to him by the Release of Information (ROI) which were for Veteran B. The documents included the cover letter from ROI.…

Outcome: 10/09/14: The Incident Resolution Service Team has determined that the Veteran will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Manager in Pharmacy reported to the facility Privacy Officer that incorrect medication was received by the spouse of a Veteran currently in hospital. The wife returned the medication which had been mis-mailed to the Pharmacy.…

Outcome: 10/09/14: The Incident Resolution Service Team has determined that Veteran B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed. 02/11/15 Update to ticket - Fact finding by manager for Pharmacy Services conducted and…