VA Great Lakes Health Care System (VISN 12)

Issue: Employee A reported 2 privacy incidents. First, the Human Resources (HR) Department mailed her a printout of her individual retirement record. When Employee A received the envelope at her house, the envelope was not sealed, but there does not appear…

Outcome: Staff education done regarding mailing procedures. Credit Monitoring letters sent to Employee A and to Employee B.…

Issue: Veteran A notified us that he had received a medication information card in the mail for Veteran B in addition to his own. The card included Veteran B's name, partial SSN and protected health information (PHI). Update: 03/12/13:Veteran B will…

Outcome: Re-training has been provided to staff concerning the importance of verifying all patient data is for the correct Veteran before mailing it/handing it to a Veteran. Correct process for notifying Veteran and Privacy Officer/ISO was also communicated.

Issue: A patient reported that following a same day surgery, his wristband was cut off by a hospital employee who then threw it into the regular garbage. The patient expressed concern that his name/SSN/DOB were not secure as it could have…

Outcome: We have re-educated staff on the importance of handling patient information in a secure manner. Staff members have been counseled on proper process for disposing of patient wristbands and the process and responsibility are being added to our facility policy…

Issue: A VA employee mailed Veteran B's appointment letter in an envelope to Veteran A, along with his appointment letter. Update: 02/25/13:Veteran B will be sent a notification letter.…

Outcome: Letter sent to patient. Privacy Officer informed ISO that appointment letter was resent to correct patient, and a notification letter has been sent to Veteran informing him that his appointment letter was mis-sent to another patient. (redacted copy attached to…

Issue: Veteran A reported that he received Veteran B's information in the mail. Veteran A stated that upon opening the letter, he saw that it was addressed to Veteran B and immediately put it back in the envelope. Veteran A will…

Outcome: Supervisor was notified and appropriate administrative action has been taken.

Issue: A Veteran was admitted to an inpatient program and went to the Inpatient pharmacy to receive education on his prescribed medication. He was given a printed medication list which belonged to another Veteran. He realized this on the way back…

Outcome: The pharmacist who accidently pulled up the wrong information has been counseled on verifying which patient information belongs to before disclosing it to a Veteran. Re-education on process and procedures has been provided to all area staff. They will see…

Issue: Pharmacy maileda prescription refill slip for Veteran A in the same envelope that contained Veteran B's medications. Veteran B immediately notified the VAMC about the improper disclosure and mailed the medication refilll slip back to the VAMC. The refill slip…

Outcome: Supervisor of responsible employee was notified of this improper disclosure and took appropriate administrative action.

Issue: An employee at the VAMC found a page of Veteran A's Progress Note in the snowbank alongside a driveway at the facility. It is not clear at this time if the note in question was given to the Veteran at…

Outcome: Supervisor of responsible employee was notified of this incident and is taking appropriate supervisory action.

Issue: A VA employee inadvertently dispensed Veteran A's medications to Veteran B. Pharmacy realized the error when Veteran A came to pick up his medications. Pharmacy immediately contacted Veteran B who returned the unopened prescription bag to the Pharmacy. The only…

Outcome: Supervisor of responsible employee was notified of this improper disclosure and took appropriate administrative action.

Issue: A controlled substance prescription for Veteran A was printed and accidently included with a new patient packet mailed to Veteran B. Veteran B returned the paper to the VA when he arrived for his first appointment (approximately 2 weeks later).…

Outcome: Additional training has been provided to staff regarding proper handling of Veteran personal information. Staff have been instructed to verify each page of a document before sending or handing it to a Veteran. PII should be secured whenever it is…