Rocky Mountain Network (VISN 19)

Issue: A non-Veteran received a letter containing a Veteran's full name, full social security number, address, and billing number. The non-Veterans wife returned the letter to the Health Resource Center and the letter has been properly destroyed. It is unclear who…

Outcome: Unable to find out what Federal Agency sent this letter to the wrong address - it was not sent from the VA Salt Lake City, because the non-Veteran who received the letter is not in our network. Please close this…

Issue: Patient A's medication was mailed to Patient B by accident. The patient who received the wrong medication brought the medication to the VAMC in Phoenix, AZ. Update: 03/15/11:Due to Personal Health Information (PHI) being exposed, Patient A will receive a…

Outcome: Meds by mail are not part of this VAMC. I have no information from the supervisor over the program what happens to the employee during these type of violations. The head of Meds by Mail said they will counsel the…

Issue: A contractor for a bio-medical device company had his car broken into. Some written material and an encrypted laptop that contained some Personally Identifiable Information (PII) were stolen. Update: 03/14/11: The laptop was encrypted. The written material consisted of a…

Outcome: HIPAA notification letters have been sent to 33 patients and the next of kin to 4 deceased patients. The vendor rep who misplaced his laptop and other documentation has been re-educated regarding the responsibilities of vendors to protect VA sensitive…

Issue: A veteran with the same name received another veterans DD214 in the mail. It contained their full name, full SSN, DOB, Service Number. Update: 03/08/11:The Veteran will be sent an offer for credit protection services.…

Outcome: 3/9/11 - Met with volunteer to inform them of the incident that occured - explained the importance of rechecking addresses, names, and the last 4 of the SSN to ensure that it was the correct veteran that would be receiving…

Issue: Veteran A's physical address was changed in VistA, and medication was subsequently mailed to the incorrect address. Veteran A called asking where his medication was. The person who received the medication by mistake also called in about it. It is…

Outcome: Review of process for address changes was performed and education provided to personnel who perform that function. Notification letter sent to patient.

Issue: The Case Manager was returning to the facility with this veterans signed authorization and when they stepped out of their vehicle, a strong wind caught the folder and the paperwork blew out onto the sidewalk. All the documents were retrieved…

Outcome: The Homeless Veterans Program case managers will be required to transport veterans documents in a closed or zippered bag from now on.

Issue: I received email from VA employee stating she was concerned with a Data Overwrite Incident.As we discussed on the phone, I was informed of a demographic data overwrite of one of our patient files this afternoon. From what I understand,…

Outcome: I called the VA National Service Desk, and they fixed the data overwrite problem. Brought this incident up to morning report and educated them to have their employees be more cautious.…

Issue: On Friday Jan. 28, 2011 the Chief, Patient Care Support Program came to the ISO and asked if either Employee A (wife) or Employee B (husband) had been into Patient Cs medical records. The reasons are as follows:A was/is having…

Outcome: Access for the offending party has been revoked and personnel action is under investigation

Issue: An ROI employee gave Veteran A the DD214 for Veteran B. When Veteran A was asked by the ROI employee, what he had done with Veteran B's DD214, he said he had thrown it in the trash. Update: 01/27/11:Veteran B…

Outcome: The employee was issued a written counseling and advised to slow down, and to take the time to ensure that any documents given to a Veteran belonged to that individual.

Issue: Mis-mailed medication packet. Update: 01/25/11: Veteran will receive a letter of notification.…

Outcome: Meds retrieved from wrong Veteran. Redacted and signed notification letter sent to Veteran.