South Central VA Health Care Network (VISN 16)

Issue: On the morning of 07/21/11 an employee discovered her office door was unlocked, opened, and office files were accessed and thrown on the floor. This area is not access controlled but open to employees, visitors and patients. Biloxi VAMC Police…

Outcome: We have conducted a full investigation. The Privacy Officer and Information Security Officer will be providing additional guidance to staff within the affected area to ensure compliance with our faculty privacy and information security policies. The VA Police continue foot…

Issue: Veteran A received Veteran B's medication. Veteran B received Veteran A's medication. Both veterans were supplied with UPS packages to mail medication back to pharmacy. recovered and destroyed. Update: 07/19/11:Both Veteran A and Veteran B will be sent notification letters,…

Outcome: Spoke to pharmacy tech about double checking medication and name before mailing.

Issue: A VA volunteer printed an inpatient listing for 07/18/11, left the office area and came back in a few minutes. The volunteer had covered the information but did not lock it up as policy states. This listing was missing when…

Outcome: The PO states the letters for these individuals went out 08 04 11. Education and training has occurred in the area. This incident has caused other areas to review their processes, too.…

Issue: Patient's medical information was mailed to wrong veteran. Information included full name, full SSN, address, DOB, and medical information. Update: 07/18/11:One Veteran will be sent a letter offering credit protection services.…

Outcome: Education/Training: met with release of information clerks reminding them the importance of checking the patient's name on the medical information being mailed to correspond with the appropriate name of the requester prior to sealing the envelope.…

Issue: Veteran was seen in PCC at LR today. Evidently when he started to leave the appointment, another Veteran/individual asked the clerk the Veteran's name. She provided it. Veteran feels his privacy was violated. He asked her why she gave his…

Outcome: Training and reminders of not divulging information. Employees provided statements... as stated, his name had already been called more than once while he was in the area... so she really didn't provide anything that wasn't already said. Letter out to…

Issue: The Pharmacy received a call from Veteran A stating that he received a package addressed to him, but had Veteran B's prep kit inside. Update: 07/14/11:Veteran B will receive a letter of notification.…

Outcome: Spoke to pharmacy tech about double checking medication and name before mailing.

Issue: It was reported that UPS lost a package. The package included Patient A's medical records from 05/20/09 to present including sensitive information. The tracking number states that the record is missing and the empty carton was discarded. Update: 07/13/11:UPS lost…

Outcome: UPS lost the package, this was no fault of the Oklahoma City VAMC.

Issue: An Administrative Assistant in the Credentialing Office reported that he had placed documents in an "in box" on his desk earlier in the morning and he stepped out of the office and upon his return discovered the documents were not…

Outcome: Staff member will keep documents containing PII in locked cabinet when he leaves the room.

Issue: Employee/patient states that employees know things that are going on and they should not know. The employee/patient has asked for an investigation to occur. Update: 07/12/11:An employee admitted to having accessed the information inappropriately, therefore, the employee/patient will be sent…

Outcome: Employee was required to take Privacy Training and Security Training and sign the rules of behavior again. Training, education and the appropriate administrative action in accordance with Human Resource Policy.…

Issue: A VA Nurse in Primary Care had a clipboard on corner of her desk that had handwritten notes by the nurse regarding employee contact information on two new employees. A third page was a Workers' Compensation Log that had names…

Outcome: Employee reminded to safeguard information in office and on desk. She has clear understanding of significance of event.…