VA Great Lakes Health Care System (VISN 12)

Issue: Employee A, who is a Veteran, suspected that Employee B had been in Employee A's medical record after Employee B commented to Employee A about a recent consult that Employee A had put in. The Information Security Officer (ISO) ran…

Outcome: Supervisor of responsible employee was notified of improper access and has taken appropriate supervisory action.

Issue: An employee copied and pasted two progress notes (one for Veteran A and one for Veteran B) into her gmail account and sent the unsecured email to someone else. The recipient of the email replied stating that employee sent the…

Outcome: Supervisor of responsible employee was notified of this violation and will take appropriate supervisory action, including education and training on the importance of safeguarding patient information.

Issue: An employee inadvertently mailed Veteran A's form letter to Veteran B and Veteran B's form letter to Veteran A. The body of the letters contained the exact information; the only difference was the salutation part of the letter that had…

Outcome: Supervisor of responsible employee was notified of the mis-mailing and is taking appropriate supervisory action.

Issue: A DoD Active duty member was mailed a radiology CD of another patient. Update: 01/03/13:One patient will be sent a letter offering credit protection services due to the disclosure of full name and date of birth.…

Outcome: Proper procedures are being reviewed with employee.

Issue: Patient A was handed patient B's discharge instructions upon leaving the ward on 12/06/12. Patient A had a subsequent hospitalization on 12/14/12, upon which he brought in the copy of incorrect information, and it was promptly shredded. Quality Management Service…

Outcome: Supervisor of responsible employee notified of improper disclosure and is taking appropriate supervisory action.

Issue: Veteran A was given Veteran B's medication at the pharmacy window. Update: 12/21/12:Veteran B will be sent a notification letter.…

Outcome: Procedure has been changed.

Issue: A VA Psychologist disclosed Veteran mental health diagnoses, psychiatric medications, medical record information and criminal record information verbally to a Child Protective Services Social Worker without written consent. Update: 12/19/12:The Veteran will be sent a notification letter.…

Outcome: Letter has been uploaded, signed by facility director and sent to Veteran. Remediation complete. Human Resources is currently working on disciplinary action for employee. Employee has also been education multiple times on the proper release of information and safeguarding of…

Issue: Veteran called to let us know he had received the information of 3 other Veterans in the mail in addition to his own. He has the documentation and gave me the names of the other individuals. Investigation is proceeding into…

Outcome: Patient letters were printed to a central location, then given to staff to put in envelopes for mailing. Staff member failed to separate documents for different Veterans which had all printed at or around the same time. Four letters were…

Issue: Another facility received a call from Veteran A that he received a letter that had his name and address on it, but the salutation was addressed to Veteran B and had Veteran B's last four of his SSN. It is…

Outcome: Supervisor of employee was notified of event and is taking appropriate supervisory action.

Issue: A VA Pharmacist inadvertently gave the medications for Veteran B to Veteran A. Veteran A noticed the error and returned Veteran B's medication to the Pharmacy. Update: 12/04/12:Veteran B will be sent a notification letter due to Protected Health Information…

Outcome: Supervisor of responsible employee was notified of improper disclosure and is taking appropriate supervisory action.