Sierra Pacific Network (VISN 21)

Issue: On 7/24/12 a VA employee intended to send a fax to a phone number with a 888 area code. However, the employee erroneously dialed the number resulting in the fax to a different number. The fax was a home health…

Outcome: All staff received refresher training regarding faxing III/PHI.

Issue: Member Services staff member forwarded correspondence to Veteran A acknowledging receipt of application for benefits. The correspondence included the cover letter, DD 214 and VA Form 10-10EZ. The information was mailed to Veteran B. The recipient returned the mis-mailed information…

Outcome: Credit monitoring letter mailed 11/2/12. And, Privacy Officer met with the supervisor of Member Service who will remind staff to take necessary precautions to ensure information is not inappropriate disclosed to unauthorized individuals.

Issue: A Veteran employee requested copy of his Sensitive Patient Access Report (SPAR). He identified names on the list that should not have accessed his chart. The Privacy Officer (PO) conducted a fact finding investigation. The chart was inappropriately accessed. Update:…

Outcome: Verbal counseling has been provided to staff.

Issue: A VA employee accessed his wife's medical records. The wife is also a VA employee. Update: 07/18/12:The employee was reviewing records in preparation for an inspection. The employee had just learned how to access Vista Imaging. After beeing shown how…

Outcome: Employee received verbal counseling.

Issue: Medications for Veteran A were mailed to Veteran B who had the same first and last name. Update: 07/17/12:Veteran B will be sent a notification letter.…

Outcome: Pharmacy staff inserviced by Supervisor regarding checking medications before mailing. Medications were returned to facility by other Veteran.…

Issue: 3/26/12@0814: Via email, the complainant contacted Occupational Health (OH) and asked if her lab results were in. 3/26/12@0843: Via a response to the complainant's email, an OH nurse replied with the titer results3/26/12@0859: The complainant asked for the specific titer,…

Outcome: Occupational Health have reviewed their practice and in the future will not include supervisory personnel on emails. Corrective actions include: 1. Privacy Office met with the Chief of OH and provided education on when information may be released from a…

Issue: A Veteran requested copies of his medical records but was sent 3 other Veterans' records by mistake. Copies were turned into the Guam VBA Office and then sent by UPS to VA PIHCS Privacy Officer (PO) . The PO has…

Outcome: Employee that was responsible for co-mingling paperwork was made to re-take privacy training. Attention to detail was reinforced.Employee that mis-mailed the documents also re-took privacy training in TMS and attention to detail was re-inforced. The scanning and release of information…

Issue: A VA Medical Support Assistant (MSA) clerk reported finding an appointment list laying on counter. The list was printed by the Administrative Officer of the Day (AOD) on 07/08/12 at 1:07 PM. The list contained patients' names and full SSNs.…

Outcome: PO educated employee, contacted supervisor to acknowledge training.

Issue: A VA Provider asked a nurse to contact a patient to reschedule his next appointment. The nurse called and left a message on the patients answering machine. The information left on the answering machine was the type of lab work,…

Outcome: Notification letter sent out on 06/22/2012. Chief Nurse and HR were contacted for appropriate actions. The nurse involved will be retraining on the Privacy Policy.

Issue: The Privacy Officer (PO) of the SF Department. of Public Health (SFDPH) contacted SFVAMC PO. Pages of what appears to be hand-written notes on various patients were found in a trash can at a public park in SF. The SFDPH…

Outcome: PO received verification that Employee completed the required Privacy training. Credit monitor letters have been signed by Director and sent via mail.