South Central VA Health Care Network (VISN 16)

Issue: A new employee accessed the record of a brother-in-law to let the wife know the medication the Veteran was on. Update: 03/26/13:The Veteran will be sent a notification letter.…

Outcome: Employee is aware and education is complete.

Issue: It has been reported by Human Resources that two employee medical files were sent from Little Rock Employee Health to the North Little Rock Employee Health Office. The two files were never received. Update: 04/08/13:Two (2) employees will receive letters…

Outcome: There is no way to determine who had the lost folder. Again, one folder was found in the office - just overlooked. Staff have been reminded the importance of always checking information. Only one letter had to go out as…

Issue: CAVHS Alternate Privacy Officer was notified today that a Veteran seen in the Emergency Department was given another patients medication. The medication was dropped from the Pharmacy by secure carrier as appropriate. The medication bottle was bagged in a brown…

Outcome: Staff were unable to determine who gave the wrong meds to the individual. Staff have been reminded of the importance of double checking before ever providing anyone with any type of meds, documents, etc.…

Issue: A Veteran requested his medical records through the Release of Information (ROI) office. When he received his records in the mail not only did he receive his records, but he received those of another Veteran with a similar name. As…

Outcome: Training has occurred for all staff by PO, reminding staff of the importance of assuring you only have one patient's information in an envelope.

Issue: Employee mailed Veteran A's password protected radiology disc to Veteran B. Veteran A could not view the images due to the password. However, Veteran B's name, type of exam and date of exam was labeled on the disc. Update: 03/21/13:Veteran…

Outcome: Employee has been educated on making sure correct radiology disc goes in the correct envelope.

Issue: Veteran A received upper endoscopy instructions for Veteran B. Update: 03/18/13:Due to full SSN and medical information being disclosed, Veteran B will be sent a letter offering credit protection services.…

Outcome: Education provided to GI Lab Nursing Service on 03/18/2013 to make sure they give the correct Veteran the correct discharge instructions.

Issue: A member of the Air National guard 138th unit reported this information to the Patient Advocate . A friend of her sister and the military member's ex-wife was given medical history and information on an Army National Guard member assigned…

Outcome: SW intern has been terminated as of 4/3/2013.

Issue: A VA employee returned a call to a family member who was admitted as an out-patient to Ward 5E. 7332 information was discussed with the father of the Veteran. The progress notes states she discussed limitations, third party affidavit, court…

Outcome: Supervisor of employee has been notified of this incident. Employee has been made aware and educated on 7332 information and opt-out status.

Issue: A VA Inpatient brought a paper to the charge nurse that contained 18 Patient's full names, last 4 of SSN, and diagnoses on it. It was left in the Patient's room. Update: 03/15/13:All 18 Veterans will be sent HIPAA notification…

Outcome: Unable to determine who left information in the patient's room. Letters went out to individual 4 2 13. Training has occurred again.. reminding staff of the importance of securing information.…

Issue: Employee A alleges that Employee B inappropriately accessed Employee A's electronic medical record. Update: 3/15/13:Investigation confirmed that Employee A's eHR was inappropriately accessed by Employee B. 03/15/13:Employees B will be sent a notification letter.05/16/13:This was determined to be HITECH reportable…

Outcome: Disciplinary action taken.