South Central VA Health Care Network (VISN 16)

Issue: The medical center Research Department was performing a routine audit of IRB approved research protocols to assure they had also received R&D Committee approval. During the audit it was discovered that a protocol had received IRB approval and the principal…

Outcome: Research protocol has been suspended until principal investigator amends protocol and HIPAA authorization to include appropriate language. Once the amended protocol and HIPAA authorization have been approved by IRB and R&D PI will be required to obtain signed HIPAA authorization.…

Issue: The Research Compliance Officer reported that a principal investigator self reported that while doing a self initiated review of research consent forms he discovered pages missing from two separate consent forms. The missing pages contain the Veteran's full name and…

Outcome: The Principal Investigator has instituted measures so as to prevent recurrence of such incidents in the future. Twice monthly, the PI is meeting with the research team to discuss all aspects of study operations and to remind all staff members…

Issue: Veteran A received his pain medication and Veteran B's prescription. Veteran B's name and type of medication was disclosed. Update: 03/12/12:Veteran B will be sent a notification letter.…

Outcome: Reminder has been shared with the staff regarding assuring that only one Veteran per set of information. Letter has been sent to Veteran.…

Issue: Employee A sent an email. The email was sent to a non-VA email address in addition to internal VA email addresses. The email had an attachment that had Employee B's info in it. The recipients of the email were VA…

Outcome: Responsible employee is no longer with the facility, however, all employees were reminded that sending any III/IIHI to an external information system is prohibited.

Issue: The VA Health Resource Center (HRC) notified the facility Privacy Officer they received a telephone call from a citizen who reported that they received a billing statement through the mail belonging to a Veteran. The HRC instructed the citizen to…

Outcome: Documentation retrieved and destroyed by shredding. Veteran's address updated/corrected in Vista.…

Issue: There was a mismailing of three Veterans' information, including full name and address. It was reported that it appears the addresses and contact information need to be updated in the facility's CPRS patient record for several patients. One is a…

Outcome: Staff have been reminded of the importance of protecting information. Letters have gone out see attached.…

Issue: Veteran A emailed a VA employee to report that correspondence he received contained a Speak To The Director form completed by Veteran B and included Veteran B's full name, last four digits of the SSN, home address and home telephone…

Outcome: Employee will assure that when printing to a shared printer she reviews documents prior to placing them in an envelope for mailing.

Issue: Veteran A was given a lab sheet for Veteran B. The lab sheet contained Veteran B's name and full SSN. Update: 02/23/12:Due to full SSN and medical information being exposed, Veteran B will be sent a letter offering credit protection…

Outcome: Service Chief will investigate and provide education to his staff.

Issue: Veteran A received his next appointment letter in the mail and Veteran B's letter was also in the envelope. Veteran A will bring letter at his appointment time. The letter contained Veteran B's name, address and diagnosis. Update: 02/22/12:Veteran B…

Outcome: Staff educated.

Issue: 'A routine post discharge follow-up call by a nurse was made to Veteran A. Veteran A reported that he had received the paperwork of Veteran B at the time of discharge. The Nurse instructed Veteran A to shred the documents…

Outcome: Numerous attempts to retrieve the documents from the Veteran were made including a home visit. Regional Counsel was consulted and indicated the facility and no additional options for document retrieval. Staff reminded to double check documentation released at discharge to…