St. Cloud VA Health Care System

Issue: Veteran A received Veteran B's medication list. Veteran B received Veteran A's medication list. Veteran A and Veteran B both mailed the lists back immediately.

Outcome: 08/19/14: The Incident Resolution Service Team has determined that Veteran A and B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: A VA employee mailed the incorrect travel voucher to 3 Veterans. In other words Veteran A received Veteran B's voucher, Veteran B received Veteran C's voucher, Veteran C received Veteran A;s voucher and Veteran B recevied Veteran A's voucher.

Outcome: 06/03/14: The Incident Resolution Team has determined that three Veterans will be sent a letter offering credit protection services.…

Issue: Three VA employees entered a patient's demographic information in CPRS.

Outcome: 05/23/14: The Incident Resolution Team has determined that Veteran B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Veteran A was mailed Veteran B's medication. The issue was discovered by staff. Staff is in the process of retrieving the medication.

Outcome: 05/02/14: The Incident Resolution Team has determined that Veteran A will be sent a HIPAA notification letter.…

Issue: Veteran A entered the Doctor's Office and set down a stack of records on the Doctor's desk. When Veteran A left Veteran A picked up Veteran A's records and Veteran B's pathology report. Veteran A returned Veteran B's pathology report…

Outcome: 04/25/14: The Incident Resolution Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: Veteran A received Veteran B's letter. Veteran B immediately forwarded the letter to Veteran A via USPS. Veteran A called to inform the VHA of the mix-up.

Outcome: 04/07/14: The Incident Resolution Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: Veteran A's medication was mailed to Veteran B. Veteran B alerted the VA to the problem and forwarded the mismailed items back to the VA.

Outcome: 03/05/14: The Incident Resolution Team has determined that Veteran A will be sent a notification letter.…

Issue: Veteran A's one sheet medical report was included in a letter mailed to Veteran B. Veteran B called and then mailed the report back to the STC VA.

Outcome: 12/20/13: Veteran A will be sent a letter offering credit protection services.…

Issue: Employee A went into Employee B's work space. Employee A began to give a short reports on Veteran A. Name and medical condition were included. Employee B informed Employee A that Veteran B was listening live via V-Tel appointment.

Outcome: 12/12/13: Veteran A will be sent a notification letter.…

Issue: Veteran A was mailed Veteran B's medication. Veteran a returned the medication the same day he received it. Veteran B's name and medication information was on it.…

Outcome: 11/21/13: Veteran B will receive a HIPAA letter of notification.…