South Central VA Health Care Network (VISN 16)

Issue: A VAMC Chillicothe employee received background investigation paperwork via UPS Next Day Air from the North Little Rock Office of Personnel and Identity Management. The forms were completes with someone else's personally identifiable information (PII). They included the other persons'…

Outcome: Staff have been retrained and reminded of the importance of assuring that they are sending the appropriate information to the involved departments.

Issue: An appointment letter was sent with another Veteran's appointment letter. The Privacy Officer (PO) has talked with Veteran A whom the letter was sent to. A letter and a return envelope was sent to Veteran A so they can return…

Outcome: Spoke with the supervisor and the clerk mailing appointments about the importance of checking each letter.

Issue: During a recent informed consent audit by the Research Compliance Officer two informed consents were found missing. One consent only had the Veteran's name and the other consent form had the Veteran's full name and full ssn. Two Veterans involved.…

Outcome: Research Compliance Officer reinforced with Principal Investigator responsibility to permanently and securely maintain research consent forms.

Issue: A VA employee transferred to another department in November 2010. In December 2010, the losing service mailed the employee's six-part competency folder to the receiving service via inter-office mail. On 05/31/211, the receiving service realized they never received the six-part…

Outcome: Staff education on mail management policies and responsibilities. Training and awareness on policies and responsibilities for competency folder hand-offs to gaining service.

Issue: Multiple appointment letters were all folded together and mailed to one Veteran. Update: 06/02/11:The appointment list contained the name of the clinic for five other Veterans. Five Veterans will be sent a letter of notification.…

Outcome: Supervisor counseled staff regarding patient confidentiality and procedures to prevent future incidents of this nature.

Issue: On 01/19/10, in completing Veteran A's request for copies of his medical records, release of information staff (ROI) sent Veteran A's medical records to Veteran B. On 03/13/10, Veteran B sent a letter to the local Veteran Service Organization to…

Outcome: This happened over a year ago and just now being reported. Error communicated to ROI staff member and reminded of importance to check work.…

Issue: Veteran A received a copy of Veteran B's audiogram consult request. The request contained Veteran B's full SSN, full name, and medical information. Update: 05/17/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: Employee completed the privacy and cyber security training module.

Issue: Upon discharge from the VAMC, Veteran B was given a copy of Veteran A's discharge instructions. The instructions contained Veteran A's full SSN, name, and medical information. Update: 05/16/11:Veteran A will be sent a letter offering credit protection services.…

Outcome: All copies were returned to the VA and shredded. All staff involved was given a copy of VHA Privacy Policy Training and Rules of Behavior to read and sign

Issue: A signed patient authorization, consult, and instructions on how to file for a claim was faxed to a restaurant instead of a Home Health Agency. This information included a Veteran's full SSN and medical information. Update: 05/05/11:The Veteran will be…

Outcome: Assistant Chief, Business Office educated the staff in regards to calling prior to faxing to ensure that the staff has the correct fax number.

Issue: An employee mailed a letter to Veteran A using recycled paper in the printer. The back of the letter contained six Veterans' names, full SSNs, preoperative diagnoses and operations. The employee did not realize other Veterans' information was on the…

Outcome: The employee has been educated. The employee will no longer recycle paper in the printers.…