Sierra Pacific Network (VISN 21)

Issue: Beneficiary Travel Vouchers were reported missing from the Redding Outpatient Clinic. The VA Police were informed of the missing vouchers on 09/07/11. They conducted a search of the facility to include dumpsters, shred boxes and offices, and was unable to…

Outcome: Trained staff on ensuring accountability for III that is mailed within the facility to ensure it is received and accounted for

Issue: On 08/05/11 a Veteran went to the lab and when she left she picked up paperwork for lab orders for 8 other Veterans. She discovered this when she got home. On 08/12/11 a VA Social Worker (SW) called the Veteran…

Outcome: The lab orders were returned.

Issue: Patient A received Patient B's test results that were printed in her record. There was a known glitch in the Tracking program that printed the wrong patient's information for records in the Medical Package. This glitch was recently fixed by…

Outcome: Reeducated employee on ensuring the information being released is going to the right patient, in addition did a verbal counseling.…

Issue: Contract CBOC employee impermissibly accessed a Veteran employee's Veteran Health Record for employment purposes to get the employees (Veteran) home address and phone number and had access to other Protected Health Information (PHI) upon accessing the record. At the time…

Outcome: The PO provided one on one training to the subject of the complaint. The employee was sanctioned (counseled) by her immediate supervisor. A credit monitoring letter was sent to the complainant.…

Issue: An employee claimed that she submitted a Personal Identity Verification (PIV) enrollment form to her service representative to be processed. Personnel Security does not have a record of receiving this individuals form. A thorough search was conducted by both the…

Outcome: The service representative will have list for the employee(s) to initial and date next to their names for submitting the PIV form to her and she will hand deliver the list and forms to Personal Security. Personal Security will verify…

Issue: The facility received notice of an Office of Civil Rights complaint from the VHA Privacy Office. The Veteran alleges that SFVAMC impermissibly disclosed protected health information (PHI) to his insurance company's attorney, which was unrelated to his claim. The facility…

Outcome: The PO met with ROI Supervisor and ROI clerk to provide verbal counseling and training on this release. PO determined the release was accidental and no malice or ill-will was meant by the release. It was an honest oversight and…

Issue: A health care provider gave the wrong sheet to another patient disclosing another Veteran's name, last 4, and medication list. Update: 08/11/11:The Veteran will receive a letter of notification.…

Outcome: Employee was verbally counseled and adjusted her current practices/processes to avoid future occurrences. Other staff members were also informed of the breach so everyone could learn from it and also adjust their processes if similar. Veteran given the wrong information…

Issue: A Fee-basis employee accessed deceased family members medical records. Update: 07/25/11:The next-of-kin will be sent a notification letter.…

Outcome: Human resources has been contacted for disciplinary action.

Issue: A letter was sent to a Veteran that contained another Veteran's name on it. Within that letter it is assumed that this other Veteran is also taking narcotics as prescribed by a physician. The letter was cut & pasted to…

Outcome: Employee will be required to take remedial privacy training. Similar letters are no longer being sent out.…

Issue: It is undetermined if this is a duplicate ticket for this incident, the reporting facility is unable to verify with the Palo Alto Privacy Officer ( PO) if another ticket has been entered. A package containing research information was sent…

Outcome: Service supervisor re-educated all warehouse staff to secure and distribute incoming packages. Warehouse staff will sign for all incoming packages in the LC logic system and tag packages with the room number where the package will be delivered. Mail clerks…