VA Great Lakes Health Care System (VISN 12)

Issue: Patient A received patient B's medication sheet in mail from the Consolodated Mail Outpatient Pharmacy. The mailing included full name and medication. No SSN or address or DOB. Update: 05/22/13:Patient B will be sent a HIPAA notification letter due to…

Outcome: Information was retrieved shortly after. No misuse of information.…

Issue: Veteran A's wristband was placed on a DOD patient's wrist Update: 04/30/13:Veteran A will be sent a letter offering credit protection services.…

Outcome: Education provided to empoyee.

Issue: A VA employee called 911 to report a threat to a staff member from a Veteran. She disclosed the Veteran's name and full date of birth. The Veteran was in an adjoining mall and not in the clinic at time…

Outcome: Employee has been educated and training will be provided to entire clinic on 5/20/13.

Issue: Veteran A was mailed Veteran B's labeled medication bottle. Veteran A will return medication to pharmacy at next appt. Update: 04/22/13:Veteran A will be sent a notification letter.…

Outcome: Pharmacy staff are still reviewing procedures to determine where breaches occur and how they can be prevented. All staff have been reminded to verify that anything mailed to a patient is going to the correct individual. The same applies for…

Issue: Veteran A called to report that he received a package from the Tomah VA Prosthetics Department with his full SSN and date of birth (DoB) on the mailing label. The SSN and DoB had been crossed out with a black…

Outcome: Employee was educated.

Issue: Medication for Patient A and B was mailed to Patient A. Medications were mailed since both patients failed to pick up the meds at Pharmacy. Patient A brought in the unopened medication bottle (with no medication missing) the day after…

Outcome: Staff are reviewing process to identify areas where breaches may occur and make any necessary changes to ensure medications are mailed to the correct patient in the future. They have been retrained on procedures for handling patient information/PHI and reminded…

Issue: UPS lost a package which contained two individual's Protected Health Information (PHI). Update: 04/08/13:Even though this is not the fault of VA, two Veterans will receive a letter offering credit protection.…

Outcome: UPS will be more careful.

Issue: Chief of Education found an OPM printout on the RICOH machine containing the Chief of Staff's name, SSN and DOB. Update: 04/04/13: The Chief of Staff will receive a letter offering credit protection services.…

Outcome: Employee was educated on securing PII when printing. Also, credit monitoring letter was sent to employee who's PII was disclosed. Request close ticket.

Issue: A VA employee received a confidential voice mail from a Veteran alerting them that they had gone to Rockford CBOC lab to pick up a collection container as instructed and when he was going to start the collection today, he…

Outcome: Staff have been notified to verify all PHI before it is handed/mailed to a patient to ensure that the information belongs to that patient. In the event that a breach occurs they have been instructed to notify the Privacy Officer/ISO…

Issue: Patient reported he was mailed a lab specimen container with a label containing his information. The envelope was torn when he received it in the mail. The information at risk included name, address and full SSN. Update: 03/13/13:The Patient will…

Outcome: No fault on VA. Envelope was torn in the mail.…