Sierra Pacific Network (VISN 21)

Issue: Veteran A was given his medical information to bring to an appointment at the referral DoD facility. When he gave the information to his provider of care, the provider noticed there was other Veteran patients' information on the backside of…

Outcome: The employee has been counseled on the incident and punitive action taken. Additional education for the CBOC staff was done and the affected employee will be required to take privacy and security training again. While the incident had extenuating circumstances…

Issue: An employee found two encounter action required reports in a bathroom garbage can. The reports contained the full name, full SSN, and date and time of appointment on two patients. Update: 05/03/11:The Two (2) Patients will be sent letters offering…

Outcome: Provided verbal education to staff in the area to ensure that patient information is placed in locked shred boxes when no longer needed

Issue: A VA employee accessed another employees' electronic health record on multiple occasions without a need to know. The employee whose information was breached states that his personal medical health information has been disclosed to others. Update: 06/03/11:The employee will be…

Outcome: Employee was made to take privacy and security training in LMS. Access to CPRS was revoked. Proposed removal from employment pending Union and Director's final review and course of action.…

Issue: Veteran A requested copies of his record. There were two printouts on a printer and the technician picked up both by mistake. They were mailed to Veteran A and he reported receiving Veteran B's information mixed in with his. He…

Outcome: Technician was verbally counseled on scrutinizing all releases going outside the organization. She is a conscientious employee and accepted the mistake along with corrective action. She also self-reported the incident after it was discovered. Notification was made to the Veteran/patient…

Issue: A supervisor at Santa Rosa Community Based Outpatient Clinic (CBOC), reported that a patient's nursing home orders were mis-faxed to an automotive dealership in Santa Rosa. The employee at the automotive dealer then forwarded the fax to the proper intended…

Outcome: Per the auto dealer, the fax was shredded on 03/29/11. Supervisor at SR CBOC provided email reminder via Vista and will provide the Privacy Office of a copy of additional privacy/security training required for two employees by COB 04/01/11. 4/22/11…

Issue: Clinics appointment dates for Veteran A were mailed to Veteran B; Veteran B returned the list to this facility. Update: 03/11/11:Veteran A will receive a letter offering credit protection services.…

Outcome: Staff will be in-serviced by Supervisor to be more diligent when mailing out information.

Issue: Release of Information (ROI) clerk mailed one form with Veteran A's signature, no other information released regarding Veteran A, the mail also contained Veteran B's list of appointments, name, ssn, address and phone number. Veteran A needs a notification, Veteran…

Outcome: Provided education to students.

Issue: Release of Information mailed the medical records of Veteran A to Veteran B in error. Veteran B called to report that he had received the medical records of Veteran A, Veteran B was instructed to return the medical records. Update:…

Outcome: Employees were in-serviced by Supervisor regarding handling of PHI.

Issue: Release of Information Clerk faxed 3 Veteran's GI reports (for Veterans A, B, and C) to Veteran A. Veteran A returned the documents to the facility. Update: 03/02/11:Veterans B and C will receive a notification letter.…

Outcome: ROI staff re-trained.

Issue: Veteran B received the cover letter for Veteran A in the mail, Veteran B notfied this facility regarding receiving the letter and that he had forwarded the letter to Veteran A. Update: 02/03/11: Veteran A will receive a notification letter.…

Outcome: Release of Information staff member counseled by Supervisor to check documents before releasing.