Sierra Pacific Network (VISN 21)

Issue: Prescription eyeglasses were addressed and mailed to the wrong Veteran (similar names). Veteran signed for the package, opened it and noticed it wasn't his. Information on the eyeglass prescription had the correct Veteran information on it. He then took the…

Outcome: Employee responsible for mis-mailing has re-taken privacy/security training in TMS.

Issue: Combined Federal Campaign (CFC) payroll copies of forms were mistakenly sent to the CFC Office when they should have been sent to payroll for automatic deductions. The payroll copies contain SSN while the contributor copy and CFC Office copies do…

Outcome: Individual responsible for delivering the wrong copies of the CFC forms was made to take privacy/security training over. Attention to detail was stressed.…

Issue: A VA employee took the lab accession sheets home and showed her husband. The information on the sheets included the full name, full SSN and lab specimen type of five patients. Update: 01/31/13:Five (5) Patients will be sent letters offering…

Outcome: Credit Monitoring letter x5 sent out, employee educated. please close ticket.

Issue: Veteran A received the lab results of Veteran B in the mail. Update: 01/30/13:Due to full SSN and medical information being exposed, Veteran B will be sent a letter offering credit protection services.…

Outcome: Credit letter signed and sent to Veteran, will request ticket to be closed.

Issue: Pharmacy prescriptions (pouches and sleeves) on Veteran A and Veteran B were mailed to Veteran C by mistake. Veteran C notified our Pharmacy and brought them back. The pouches appeared untampered with and the sleeves were in sealed packages which…

Outcome: Items were recovered by pharmacy technician responsible for the mis-mailing. The employee took privacy/security/rules of behavior and privacy/HIPAA training over again in the Talent Management System (TMS).…

Issue: Veteran A was sent a printed radiology report and a CD with images that was meant to be sent to Veteran B. Update: 01/11/13:Veteran B will be sent a letter offering credit protection services.…

Outcome: 1. Staff responsible for processing radiology ROI requests instructed to completed TMS training VA 102032. The procedures for processing requests changed (individual versus batch processing)3. Procedures will be documented in an SOP4. Recommended the service conduct quarterly audits5. Credit monitoring…

Issue: On 1/11/13 at approximately 8:50 a.m., SFVAMC's Chief of Health Information Service (HIMS) and Release of Information (ROI) Supervisor came to the Privacy Office to report Veteran A received Veteran B's MRI report. Update: 01/11/13:Veteran B will be sent a…

Outcome: 1. Staff responsible for processing radiology ROI requests instructed to completed TMS training VA 102032. The procedures for processing requests changed (individual versus batch processing)3. Procedures will be documented in an SOP4. Recommended the service conduct quarterly audits5. Credit monitoring…

Issue: A San Francisco VAMC physician called to report receipt of a UPS express envelope that was opened and then reclosed (stapled shut) buy an unknown person. The physician reported the envelope was mailed by the VA Southern Nevada HCS and…

Outcome: Credit monitoring letter sent, and Mail Room staff now document when they must open receivables in the Mail Room. No additional mitigating actions are required since we could not determine who opened the UPS mailing envelope…

Issue: A VA employee accessed the record (view registration screen) of her spouse (from whom she is separated) to obtain insurance information. Update: 01/09/13: The spouse will receive a HIPAA letter of notification.…

Outcome: Notification letter sent, action taken with employee, please close ticket

Issue: Visitor on the grounds found a Veterans C & P File near a dumpster, lying against a pole behind our facility. The visitor gave it to his sister and she return it to the facility on 12/20/2012. Update: 12/21/12:Due to…

Outcome: Credit Monitoring sent out to Veteran. Continue to follow up with site chief about UPS delivery. PO forward ticket and action to the senders site Privacy officer. After entering the PSET ticket- PO contacted the Clinical Support Chief and turn…