South Central VA Health Care Network (VISN 16)

Issue: Veteran A received Veteran B's lab results in the mail. Update: 01/24/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Educated the staff.

Issue: A staff member reported she suspected her medical record had been entered without proper authorization or justification. Update: 01/23/12:The employee will be sent a letter offering credit protection services, because her supervisor and another employee accessed her medical record which…

Outcome: LETTERS OF COUNSELING GIVEN TO TWO INDIVIDUALS WHO ACCESSED WITHOUT JUSTIFICATION. INVIDUALS ALSO REQUIRED TO COMPLETE TRAINING. REDACTED CML, DATED 1/23/12, ATTACHED.…

Issue: There was a complaint emailed to VA Police Chief, Privacy Officer, and Information Security Officer to report a missing audiotape. On Thursday January 19, 2012 the Nurse Manager noticed that the Audiotape with testimony was missing from her office. As…

Outcome: Staff to assure door to office is locked when not occupied and documents/tapes etc. containing PII maintained in locked cabinet.

Issue: A VBA Regional Office Privacy Officer (PO) notified the facility PO that a one page document was recovered by the mailroom. The document was taped to the side of a box that was shipped via UPS to their facility from…

Outcome: This is an isolated event. The mail-out process has been reviewed and modified to "double-check" all boxes prior to shipment. Staff received education, training and awareness for security and privacy safeguards.…

Issue: An individual received Veteran A's statement of medical care cost recovery account activities for December 2011. It was from the North Little Rock Agent Cashier. The individual called the Health Resource Center (HRC) to report this incident and then was…

Outcome: PO has been in contact with several services and was unable to determine exactly who mailed this out to this individual. Staff in all areas have been reminded that they should always verify the address before mailing out. There is…

Issue: Veteran A received his clinic appointment letter and there was two other Veterans appointment letters in the envelope with his. Appointment letter contain first name, partial SSN, and medical information. Update: 01/05/12:Two (2) Veterans will be sent a notification letter.…

Outcome: We have re-educated the staff involved

Issue: Veteran A, who is also an employee, received an appointment letter belonging to Veteran B. The appointment letter was turned in to the Privacy Officer (PO). The letter contained Veteran B's first and last name and medical information. Veteran B's…

Outcome: The Service will conduct a process evaluation to identify areas for improvement and reoccurrence prevention.

Issue: Veteran A came to the pharmacy window to pick up his medication it was not ready, he was ask to step to the side and the tech waited on Veteran B. The tech motioned to Veteran A to come to…

Outcome: Supervisor counseled pharmacy technician to be more attentive to what each Veteran was picking up at the window.

Issue: A VA Patient who is a Compensated Work Therapy (CWT) employee, reported that his Protected Health Information (PHI) was revealed. He previously was admitted to the inpatient psychiatric ward in August 2011. He was working with a housekeeping employee and…

Outcome: Supervisor/Privacy Officer will provide in-service education on release of sensitive information.

Issue: Release of information clerk released copies of a deceased Veteran's medical records without proper authorization. Update: 12/27/11:The Veteran's Next of Kin will be sent a notification letter.…

Outcome: Employee who released the records has retired, however, 1/12/12 supervisor of ROI unit held a inservice with entire ROI staff to re-educate on the release requirements for deceased Veterans.