Phoenix VA Health Care System

Issue: Today, 10/17/13, Pharmacy Supervisor reports a call by Veteran A describing receipt of a medication for Veteran B. Upon review, it was the same medication, same dose and strength for each Veteran. Medication was provided to each Veteran on 09/17/13.…

Outcome: 10/17/13: HIPAA notification letters will be sent to two Veterans.…

Issue: Today, staff reported to the Privacy Officer (PO) and their manager that they received a Sensitive Patient Access Report (SPAR) yesterday from PO. They indicate that 2 staff members who accessed their medical record did not correlate with services requested…

Outcome: 10/23/13: Human Resources' (HR) fact findings show that one individual did access the staff's chart without permission; the other did not. This escalates the ticket to an Incident. The Associate Director indicates that he has contacted Health Administration Services (HAS)…

Issue: Today, 10/7/2013, Chief reports that a Veterans financial application for Arizona military family relief fund financial assistance form was faxed to an unknown recipient on 10/4/2013. The fax number for Arizona Department of Veterans Services was obtained from a colleague…

Outcome: 10/07/13: Veteran A will be sent a letter offering credit protection services.…

Issue: Today, 10/03/13, the Privacy Officer (PO) receives report from employee that clinical co-worker mentioned that she was accessing her sons electronic medical record. CPRS was open to the sons medical record during discussion. Clinical staff stated that they opened sons…

Outcome: 10/08/13: The PO discussed the case with the employee's Supervisor, who had been away from the office. She will address questions with her nurse to understand if she was accessing her son's chart, if her son is a Veteran receiving…

Issue: Today, 10/03/13, an employee reports that 2 other staff at the facility accessed his electronic medical record without his permission or job functions. The employee had received a Sensitive Patient Access Report (SPAR), by request. The 2 other staff members…

Outcome: 11/13/13: Supervisor provided reports for both staff members. Supervisor provided an analysis of prospective actions which varied from other actions previously occurring in this service line. Chief reviewing SPAR actions for this and other SPARs requested tomorrow. 11/14/13: Discussed with…

Issue: Today, 9/20/2013, a privacy incident was reported to PO as part of a VISN18 Suspense. A facility physician emailed Senator John McCain expressing several Veteran concerns. The email disclosed five suicide cases which included the Veterans first name and last…

Outcome: 09/24/13: After further investigation, the physician has accessed fifteen known charts with out proper authorization. The physician released five deceased Veterans' PHI to the Senator's office. Those five Veteran's next-of-kin will be sent letters of notificatoin.…

Issue: On 07/30/13, the central coordinating center for a multi-site VA study governed by the VA Central Institutional Review Board (CIRB) contacted the local site Research Coordinator to request re-faxing of consent form and HIPAA Authorization for one subject consented 03/19/13,…

Outcome: 09/03/13: The CIRB did request that the study obtain new forms retroactively, and that was accomplished. The timeline is as follows: On 7/30/13 the study reported the deviation to the CIRB. CIRB reviewed the deviation report on 08/06/13. CIRB requested…

Issue: Veteran B picked up medications from the Pharmacy and found Veteran A's medications included in the package..

Outcome: 08/21/13: Veteran A will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: On 8/1/13, a Pharmacy technician processed an address change for Veteran A. Address change was mistakenly applied to the chart of Veteran B, who has a similar name and last 4 SSN. Veteran B received two packages of medications intended…

Outcome: 08/09/13: Veteran A will be sent a letter of notification.…

Issue: Today, 08/07/13, Pharmacy supervisor reports that Veteran B and Veteran A called him to report that Veteran B received two of Veteran As medications. Veteran B was not expecting medications so he did not open medications packages delivered to him…

Outcome: 08/08/13: Veteran A will receive a HIPAA letter of notification.…