VA Great Lakes Health Care System (VISN 12)

Issue: A VA employee took consult sheets home and left them in a bag in her unlocked car overnight. Her car was broken into and the bag taken. It was found the next evening two blocks away with all items intact.…

Outcome: The employee has been counseled not to remove PHI from VA premises without permission from her supervisor and the Privacy Officer and/or ISO. Additionally, all staff have been briefed as to proper procedures for handling PHI and removing PHI from…

Issue: Patient A received Patient B's information in the mail regarding Vocational Rehabilitation and claim forms. Patient A promptly returned the information to the Privacy Officer. Patient A would like a promotion code for credit monitoring because she does not know…

Outcome: Education provided on accuracy of information. The second Veteran whose information was mismailed was not identifiable other than name and last four and is not in the VA system. No letter provided. Letter provided to Patient A who received the…

Issue: Patient A received Patient B's medications at the Pharmacy window without any paperwork, only the medications with the labels. The error was discovered before Patient A left the building. The medications were retrieved and corrected. No violation found. Update: 05/19/11:Due…

Outcome: Employee was counseled on accuracy of information and checking information before disclosing.

Issue: Veteran A was mistakenly given a CD containing information on Veteran B. Update: 05/10/11:Veteran B will be sent a letter offering credit protection services due to full name and full SSN being exposed.…

Outcome: Employee has been educated and verbally counseled to pay greater attention to detail while conducting duties.

Issue: Patient information that was mailed never arrived at the destination. Update: 05/09/11:Veteran A will be sent a letter offering credit protection services.…

Outcome: A tracking log and mail tracking number have been implemented to improve tracking, receipt and delivery of packages.

Issue: A patient List for Rounds Summary was found in a utility room. Update: 05\03\11:The utility room is not accessible to the public, however, it is not known how the list got there or how long it has been there. Eight…

Outcome: The chief reiterated how important it is to safeguard PHI with all employees. The topic will be brought up again. We perform weekly rounds throughout the hospital.…

Issue: Employee A received Employee B's progress notes. The mistake was realized and both veterans contacted. Information which included full name, full SSN, and medical information was returned. Update: 05/03/11:Employee B will receive a letter offering credit protection services.…

Outcome: Employees were reminded of accuracy when dealing with sensitive information.

Issue: Patient A received Patient B's prescribed medication and dosage. Both patients are receiving care at Community Based Outpatient Clinic. Update: 04/28/11:Patient B will receive a letter of notification.…

Outcome: Re-emphasized the importance of following VA processes and procedures to the staff to ensure patient safety and privacy are protected.

Issue: An active duty service member being separated from service states that his original service medical documents were lost during the compensation and pension (C&P) examination. Update: 04/22/11:The service member reported this to the Privacy officer (PO). The PO contacted the…

Outcome: A written receipt will now be given to anyone who gives their medical record to the Special Medical Exam Unit.

Issue: Lab results for Veteran A were mailed to t Veteran B. The results included Veteran A's name, address and diagnosis and lab test results. Update: 04/19/11:Veteran A will be sent a notification letter due to Protected Health Information being disclosed.…

Outcome: Employee was re-educated.