VA Great Lakes Health Care System (VISN 12)

Issue: A foreign podiatry student asked to visit VA Medical Center and observe. The student has not taken any privacy/information security awareness training and has no affiliation with VA. The student "shadowed" a podiatry resident for a "few hours" and was…

Outcome: Staff has been re-educated on privacy. Individual re-took Privacy training. Stronger identification procedures are in place in the clinic to identify visitors from staff. Visitor policy is being revised.…

Issue: A provider gave a patient a piece of paper but did not realize there were several other pieces of paper attached containing about 10 Veterans progress notes, appointment lists containing appointments and full SSNs. The provider realized it about 15…

Outcome: The provider was educated on privacy and protecting information.

Issue: Two VA Social Workers disclosed information on one Veteran to the court system without appropriate Release of Information (ROI) permission. Update: 03/29/11:The Veteran will be sent a notification letter, due to Protected Health Information being disclosed.…

Outcome: The two Social Workers as well as other Social Workers were provided education by the PO on the content requirements for a sufficient authorization, emphasizing 7332 information.

Issue: Ambulatory Care Supervisor reported to the Privacy Officer that on two different occasions, a psychiatrist sent lists of patient data to the Travel Office with a patient as verification of the patient's attendance in clinic that day. The verification is…

Outcome: Privacy Officer re-emphasized importance of everyone's role in safeguarding VA sensitive material. Patients are checked out electronically. As of beginning of May 2011, Jesse Brown VAMC instituted new policy where eligible patients are receiving Travel Pay benefits via mail.…

Issue: When responding to a FOIA request, an employee failed to redact patient information. Update: 03/16/11:The patient will receive a notification letter.…

Outcome: The PO spoke with the Associate Director about ensuring that all redactions were completed promptly and accurately. The PO also reviewed the required and recommended procedures and policies regarding redactions with our previous privacy/FOIA officer.

Issue: Veteran A received Veteran B's appointment letter along with his appointment letter. Update: 02/22/11:Veteran B will receive a notification letter.…

Outcome: The original appontment letter was retrieved. Notification letter was sent to veteran on February 28, 2011.Redacted Notification Letter uploaded.

Issue: A log book is missing from the locked room where it was stored. Update: 03/16/11:On February 21, 2011, an Ambulatory Surgery log book containing full patient name, full SSN, DOB, surgery follow-up, and the lot number of the specific pill-cam…

Outcome: We have not been able to locate the log book. Staff believes it fell into the wastebasket; however, trash compactor was cleared out before Privacy Officer and VA Police were notified of the incident. We are in the process of…

Issue: Veteran A was mailed Veteran B Medication List. Update: 01/28/11: Veteran B will receive a letter of notification since his name and last four of his SSN and medication information was exposed.…

Outcome: Medication list was mailed back to veteran. Notification letter was mailed to veteran on Feb 11, 2011. copy of redacted letter sent to VA IRCT Mailbox on Feb 11, 2011.

Issue: Pharmacy mailed prescription for Patient A to Patient B. Both patients were notified within 12 hours of mailing. Information was recovered. Update: 01/21/11:Patient A will receive a letter offering credit protection services since his full SSN was exposed.…

Outcome: Staff were educated on accuracy of information. Veteran notified. Ticket can be closed.…

Issue: Missing medical record. File room personnel report transporting it to Community Based Outpatient Clinic (CBOC). CBOC personnel have no record of receiving it. Update: 01/13/11:Due to PHI and full SSN,Veteran A will receive a letter offering credit protection services.…

Outcome: When transporting medical records between file room and CBOCs, all future requests will be forwarded with a trip ticket and return receipt, specific for medical records.