South Central VA Health Care Network (VISN 16)

Issue: Veteran A notified the Community-Based Outpatient Clinics (CBOC) that he received Veteran B's mail. The Privacy Officer (PO) contacted Veteran A who reported that he received 4 pages of Veteran B's appointment letters. Documentation on letters reviewed and contain appointment…

Outcome: Facility awaiting return of documentation from Veteran A. Service area unable to determine if incident occurred as a result of human or machine error.…

Issue: A patient met with the Acting Privacy Officer (PO) and noted that his Medical Information had been accessed by a VA employee that was related to his fianc'. He noted that he had not been seen at the VA; however,…

Outcome: Chief of Primary Care had the Employee complete the VA Training on Privacy and on Information Security even though the employee was currently compliant with that training. Certificates of Completion were to be turned in to the Chief of Primary…

Issue: Administrative Officer (AO) for the Neurology Care Line that while searching for records in her file cabinet she discovered several folders missing. One of the folders included copies of medical records on a patient. Other folders discovered missing included information…

Outcome: Office have been rekeyed.

Issue: A call was received from Veteran A that she received medication and a progress note from the medical record of Veteran B. Veteran A would return the medication to the Community Based Outpatient Clinic (CBOC) in Tulsa and destroy the…

Outcome: PO met with Veteran and pulled access to sensitive record report, discussed access, appt etc. Also had a fileman routine ran, completed by Pharmacy staff to see who changed her address. Veteran is satisfied it was a clerical error.…

Issue: Veteran A's daughter sent an email to the Medical Center Director to report that a VA employee driver spoke to the apartment manager (who is also Veteran A's employer) about his medical condition. Update: 02/03/12:The Veteran will receive a letter…

Outcome: Supervisor counseled the employee and will provide training to all staff members in the February meeting.

Issue: Employee found a piece of plain white paper where a provider had written notes concerning seven (7) Veterans. The note was found near the hallway between PET/CT (radiographic procedures) AND Emergency Room (ER) area. Both patients and employees have access…

Outcome: Resident required to retake VA10203 Privacy and HIPAA training.

Issue: Veteran received a copy of his medical record. Within the medical records he received was an ECG report that had another Veteran's name and full ssn at the top of the page. The Veteran returned the ECG to the facility.…

Outcome: Report corrected removing incorrect information.

Issue: The facility Safety Officer was walking back to his office when he found a steno notebook with notes about home base primary care patients. Update: 02/01/12:In the steno notebook were the last names, last four of SSN, and lab results…

Outcome: Doing a facility wide training on logbooks.

Issue: A package of VA employee combined Federal Campaign pledge forms that contained employee names, SSNs and other information was routed through the internal mail system and failed to arrive at Fiscal Services office. Tracers were performed but to date the…

Outcome: Individual directed to complete Privacy Act refresher training.

Issue: Veteran A called his primary care team and stated he had one of Veteran B's prescriptions in his bag of medications that he had picked up at the window. Update: 01/24/12:Veteran B will be sent a notification letter due to…

Outcome: We have reeducated the staff involved.