South Central VA Health Care Network (VISN 16)

Issue: 2 VA employees were walking to their vehicles on 02/15/2011 when they noticed there were 4 patient armbands stapled together lying on the sidewalk. It is believed that a VA nurse lost the armbands outside on 02/08/2011. Update: 02/18/11:Four Veterans…

Outcome: Education is being done with all nursing staff on security and privacy. The appropriate administrative action is being taken in accordance with Human Resource Policy with the nurse who printed the armbands.…

Issue: VISN ISO found the 2nd page of a medication list on the step outside the facility. The page contained the patient's full name, last 4 of his SSN and medication information. Update: 02/17/11:Patient will receive a letter of notification since…

Outcome: No violation found. The veteran lost his information after he left the building.…

Issue: Employee accessed remote data in CPRS on another Employee(Veteran) and disclosed the information to another employee (manager) Update: 02/18/11:Employee will receive a letter offering credit protection services since thier full SSN was exposed.…

Outcome: The employees was sanctioned and will be provided additional privacy training.

Issue: Veteran A received a letter from the Regional Office which contained Veteran B's claims folder review letter. Update: 02/16/11:Veteran B will receive a letter offering credit protection services.…

Outcome: Veteran was notified of mis-mailed document and provided credit monitoring. The mis-mailed document was attached to the credit monitoringletter for the Veteran's information/action.Unable to determine who at the Muskogee, OK, center mis-mailed the document.No further action required. Request ticket closed.…

Issue: Signed Health Benefits package was sent to the incorrect employee. This information was addressed to 2 different employees and hand delivered to the correct recipient by a third person, all who had access to the information. Update: 02/16/11:Employee A will…

Outcome: Employees within the responsible service will be provided education on the importance of safegaurding confidential information.

Issue: The nurse manager of 4B stated that a medication administration sheet containing name, full social, and medications of all patients on 4B (26) dated 2/6/11 had been discovered in a patient's room on the evening of 2/9/11. The patient had…

Outcome: The nurse in question acknowledged her role in the incident and has retired from the facility. Education on patient confidentiality and privacy is being completed with all 4B staff. Redacted letter sent 3/7/11.…

Issue: Patient A called his Primary Care Team Clinic to say that he received an appointment letter and clinical notes on Patient B. The documents included Patient B's name, full SSN, DOB and protected health information. They came in an envelope…

Outcome: Patient A returned the appointment letter to the facility and I have included it with packet. I have spoken to the Primary Care team about being more diligent when mailing out PII.

Issue: PO rounding in the NLR Campus basement found the VA Form 21-686c folded on a crate behind the canteen area. There is no way to know when this was left there. Has the Veteran's full name, social security number, address,…

Outcome: Unable to tell how information arrived at where PO found it.Credit Monitoring letters did go to individual and spouse dated February 11, 2011.…

Issue: Veteran A reported via telephone that he received an appointment letter pertaining to Veteran B. The letter contained Veteran B's full name and last four of the SSN. The PO was notified and contacted Veteran A to recover the document.…

Outcome: Involved employee to receive additional training regarding privacy.Notification and credit monitoring letter forwarded to involved Veterans.Redacted copies of letters submitted to IRTC for closure.

Issue: Veteran A reported to the pharmacy with a package he received in the mail. The package contain medication for veteran B. The package contained home medications for veteran B that was collected when veteran B became a inpatient. The pharmacy…

Outcome: Letter has been mailed to veteran on 2/4/11