Sierra Pacific Network (VISN 21)

Issue: A Vendor who provides cardiovascular implants and who also participates in surgeries at this facility reported that his briefcase that contained his company laptop was stolen from his vehicle this morning. His laptop contained the CT scan images for two…

Outcome: Upon investigating this incident with the Vendor and Surgery Service, it was discovered that images for implants were provided to a vendor on a CD for review to allow the vendor to determine what cardiovascular implants might be required. The…

Issue: A letter of authority (LOA) was sent to the wrong address. The envelope had Patient A's name but the address belonged to Patient B. Update: 04/03/12:Patient A will be sent a HIPAA notification letter, as his medical information was disclosed.04/18/12:This…

Outcome: Action plans:1. IRM will create a database similar to the mailing labels database where in the clerk enters the patient's name and his address on record is seen. FB clerk will copy/paste this information into the automated letter envelope. In…

Issue: Veteran A received a pill bottle for Veteran B. Veteran A returned the medications to VA control. Update: 03/29/12:Veteran B will be sent a notification letter.…

Outcome: Notification letter mailed 3-29-12, Manager for unit from where meds were dispensed to wrong patient has initiated education and training with her staff.

Issue: Veteran A received a prescription slip for Veteran B with lab results letter. Veteran A contacted the clinic that mailed the information out and was instructed to shred the information of Veteran B. Update: 03/23/12:Veteran B will be sent a…

Outcome: Credit monitoring letter mailed out 3-23-12, redacted copy uploaded to PSETS. Individual who may have been responsible for mis mailing information has been reassigned duties.…

Issue: Veteran A called to report receiving the lab results of Veteran B. The clinic area that received the call instructed Veteran A to shred the letter the clinic staff then advised Veteran B of the mismailing. Update: 03/26/12:Veteran B will…

Outcome: Credit monitoring letter mailed out 3-26-12, redacted copy uploaded to PSETS. Individual who may have been responsible for mis mailing the information has reassigned to other duties.…

Issue: Veteran A received the chest x-ray results of Veteran B along with her lab results. Both results were sent in the same envelope to Veteran A. Veteran A contacted the facility Privacy Officer to report this and Veteran A was…

Outcome: Document retrieved and staff responsible to be educated.

Issue: Veteran A received the non-VA Radiology Reports belonging to Veteran B in the mail in addition to her own records. Veteran A reported this incident to the local news station. The information at risk includes Veteran B's name, address, date…

Outcome: Provided education to the employee on the proper safeguarding of patient information while mailing.

Issue: Veteran A received the appointment letter of Veteran B. The letter had full name and address along with last four of SSN and appointment information. Update: 03/09/12:Veteran B will receive a letter of notification…

Outcome: Notification letter sent, please close ticket

Issue: Two pages of Veteran A's medical record had been erroneously scanned into another Veteran's medical record. In response to a valid Release of information request the medical record was faxed to a third party. After the medical record was released…

Outcome: Recipient of faxed information was contacted, unintended information was identified and destroyed. Scanning Vendor was contacted and mis scanned records were rescanned to correct record. Release of Information staff have been educated to review records for misfiling before releasing. Credit…

Issue: Copies of Veteran A's health care information were mis-mailed to Veteran B by mistake. The information contained Veteran A's name, full SSN and protected health information (PHI). Update: 02/21/12:Veteran A will receive a letter offering credit protection services.…

Outcome: Counseled individual responsible for the inadvertent disclosure. Also alerted others responsible for disclosing similar information to be cautious of what's being released and stuffed into the envelopes.…