Sierra Pacific Network (VISN 21)

Issue: Three Veterans discharge summary were inadvertently sent to three email groups thru MyHealtheVet secured messaging. The sender intended to send the PHI to three providers not knowing that other Veterans were recipients of the group email. Update: 11/06/12:Due to Veterans…

Outcome: MyHealtheVet (MHV) help desk unable to assist in recalling unopened/unread emails within the distribution groups. A second email was sent urging recipients to delete the first email sent in error. VAPAHCS is in the process of reviewing our distribution group…

Issue: A VA Pharmacy tech gave Patient A's prescription to Patient B. The prescription contained Patient A's name, date of birth and medication information. Update: 11/05/12:Patient A will receive a letter offering credit protection services.…

Outcome: Compromised information was retrieved on the same day incident was reported. Employee responsible for medication mix up was counseled and will be required to take privacy/security training over again in TMS. Will suggest to Chief of Pharmacy that they conduct…

Issue: Veteran A's prescription bottle was mis-labeled with Veteran B's label. The label included Veteran B's name and medication name. There was no other identifying or personal information involved. Update: 10/25/12:Veteran B will be sent a notification letter.…

Outcome: The person responsible for placing the incorrect label on the prescription bottle has been counseled on attention to detail and to double check so this doesn't reoccur.

Issue: An unidentified employee provided a Patient's home address and phone number over the phone to someone who did not have authority to obtain the information. Caller was from a local homeless program trying to assist their client with obtaining information…

Outcome: Remind staff to ensure they have legal authority to release patient address and phone number to 3rd parties.

Issue: A patient alleges that a nurse called his home and since he was not home provided information to his mother regarding his medical treatment Update: 10/11/12:Patient A will be sent a notification letter.…

Outcome: No violation was found as under HIPAA this was ok and our local policy on urgent lab results was followed.

Issue: A Primary Care nurse gave a lab paper to the wrong veteran. Update: 10/05/12:Due to full SSN being exposed, Veteran A will be sent a letter offering credit protection services.…

Outcome: Credit Monitoring letter sent, educated employee.

Issue: A Veteran presented a one page lab letter she received in the mail and pointed out that on the back of the letter are two Veterans' appointments containing their full name, SSN, service connected disability percentage, phone number, means test:…

Outcome: Retraining to involved employee done. Clerk Supervisor will extend re-training to all the staff within her jurisdiction on this issue. Individuals involved were sent notification letters with credit monitoring codes.…

Issue: Veteran A's prescription was mailed to Veteran B. The recipient called the hospital to report the error. The package contained the medicine with full name of Veteran A on the label, direction for use and drug information. Update: 09/18/12:Veteran A…

Outcome: Notification letter sent to Veteran Verbal counseling to employee involved.…

Issue: Patient A recieved copies of Patient B medical records from the Release of Information Office on September 6, 2012. Update: 09/18/12:Patient A will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: Provided verbal education to the employee to ensure to review all records that are being released belong to that individual prior to releasing.

Issue: On 09/14/12 at approximately 2:00 AM, Patient A was discharged from the Emergency Department and given a copy of the discharge instruction form that was entered and printed from another patient's chart. Therefore, the printed document contained Patient B's full…

Outcome: Discussed with the provider (who self reported the incident as well as contacted the Veteran) and he will be more cautious in the future to prevent this type if incident from recurring. And, credit monitoring offered to the Veteran whose…