Sierra Pacific Network (VISN 21)

Issue: A fee basis employee/phlebotomist posted a picture of numerous vials of blood with sensitive patient information visible on her personal Facebook page. The patient's full name, social security number, date and time blood drawn, and type of lab work were…

Outcome: Credit monitoring letter have gone out. The Facebook page has been removed and Human Resource was contacted. All employees in Pathology and Lab will be retraining on HIPAA and Privacy regulations and best practices.…

Issue: A Supervisor of Release of Information (ROI) called to notify Privacy Officer (PO) that Veteran A reported he received Veteran B's medical records in the mail in error. Veteran A received a compact disc (CD) in the mail 5/31/12 and…

Outcome: Credit monitoring letters have been sent out. Employee responsible for the error received immediate counseling and education from the supervisor and the department is taking the corrective action for this matter. In addition, the supervisor of employee has provided an…

Issue: Patient A, brought the Patient Advocate, 128 pages of another Patient's records he received from Release of Information (ROI). His concern is that his records may have gone to the other patient. Patient A returned the records to Patient Advocate.…

Outcome: Employee was educated regarding responsibility to ensure disclosing information to the appropriate patient/requestor.

Issue: Clinic staff were unable to locate a physician's patient verification sheet. Upon investigation it was determined that a Patient had accidently took it home with their own information. The clinic staff immediately contacted the patient whom confirmed possession of the…

Outcome: Check in sheets have now been placed in binders rather than folders to prevent them from being misplaced with other paperwork.

Issue: Scanned copies of consultations from civilian providers were mistakenly scanned into the wrong patient chart. When the patient asked for a copy of his medical records, he received the other patients information. Update: 05/10/12:Veteran B will be sent a letter…

Outcome: We worked with the supervisor to identify the cause of the mis-scanned documents that were placed into the wrong patient chart.The incorrect information were removed from the electronic health records and placed into the correct records.

Issue: A VA Patient came to the VA Release of Information Office to request medical information be provided to his insurance company and place of work. The place of work was to receive a notice from the patient's care provider concerning…

Outcome: Employee responsible for faxing document to be provided with training and education.

Issue: Patient A received a letter in the mail. The letter was mailed on 4/27/2012. The letter had patient A's name and mailing address showing through the window on the envelope. Patient A read the letter which contained an appointment notification…

Outcome: Supervisor to in-service staff regarding precautions when mailing patient information.

Issue: An individual notified the Privacy Officer (PO) that several staff members were huddled around a monitor reviewing the medical record of a now deceased individual. Update: 05/07/12:The Veteran's Next of Kin will be sent a notification letter.07/31/12:An appeal was filed.…

Outcome: 1. On 5/4/12, an email was sent to all employees reminding them of when employees may use or access individually-identifiable health information2. All staff who were asked why they accessed the patient's chart were re-educated that the official use of…

Issue: A VA employee, who was recently in the news for a violent crime, had his medical record accessed by another employee. Update: 04/30/12:The Veteran will be sent a HIPAA notification letter.…

Outcome: Action taken by HR. Notification letter sent to last know address…

Issue: A VA employee in the Release of Information (ROI) Office faxed the records of Veteran A to Veteran B; Veteran B returned the mis-faxed records to this facility. The information disclosed included Veteran A's name, address, full SSN, date of…

Outcome: The employee that faxed the information will be inserviced and counseled by the Supervisor.