VA Great Lakes Health Care System (VISN 12)

Issue: Employee sent unencrypted e-mail message with PII to another veteran (cc'd the wrong veteran) Update: 11/30/12:Due to PHI being sent to wrong Veteran, Veteran B will be sent a notification letter.…

Outcome: Notification Letter sent and employee educated.

Issue: Veteran A called and stated that he received a letter from the VAMC that contained an appointment letter concerning Veteran B. Veteran A stated that the appointment letter stated that Veteran B had an appointment at a certain time and…

Outcome: Supervisor of responsible employee was made aware of inappropriate disclosure and is taking appropriate supervisory action.

Issue: Patient A was wearing Patient B's arm band. Patient A passed away. Patient A's family member took Patient B's arm band and would not return it, when asked by VA staff. Update: 11/02/12:Patient B will be sent a letter offering…

Outcome: Staff have been reminded of the need for accuracy when handling patient information.

Issue: Veteran/Employee was hospitalized. Security audit shows other employees may have inappropriately accessed the employee's CPRS record. Investigation continuing to determine whether access was inappropriate or not. Update: 11/26/12:Investigation is ongoing due to staff schedules.12/03/12:The Veteran/Employee will receive a notifcation letter.…

Outcome: Per my comments below: Of the 11 staff who were interviewed, it appears 3 did not have a job related reason to access the Veteran's record. HR and the service chief are determining discipline for these individuals. Education has been…

Issue: Veteran A received some medical records of deceased Veteran B. Update: 10/26/12:Veteran B's Next of Kin will be sent a NOK notification letter.…

Outcome: Staff have been re-educated about double checking medical records before being mailed out.

Issue: Pharmacy dispensed Veteran A's medication to Veteran B by mistake. The error was discovered within one hour when Veteran A came to pick up Veteran A's medication. Veteran B was immediately contacted about the mistake, and Veteran B promptly returned…

Outcome: Supervisor of responsible employee was made aware of incident and is taking appropriate supervisory action.

Issue: Veteran A recently sent in a request to have Veteran A's address changed in our system. The employee who handled this request mistakenly changed Veteran B's address rather than Veteran A's. Veteran A and Veteran B have very similar names.…

Outcome: Supervisor of clerks was made of aware of the incident and is taking appropriate supervisory action, including providing additional training/education to all clerks.

Issue: The scanning department accidently imported Veteran A's fee basis records into Veteran B's record. Veteran B received a copy of them after requesting a copy of all his medical records. The records included Veteran A's name, full SSN, date of…

Outcome: The information has been removed from the incorrect record and scanned into the correct record. Scanning/import staff have been re-trained on procedures and reminded to verify identity before adding something to a patient's record. Release of Information staff have also…

Issue: Veteran A presented to Patient Advocates office stating he received Veteran B's medication list from a clinic staff member several weeks earlier. He did not receive his own list. He returned the Veteran B's medication list to the Patient Advocate…

Outcome: Privacy Officer is meeting with Nurse Managers to determine whether there is a system issue or individual error. Staff have been re-trained on process of providing CPRS information to Veterans and reminded to review all pages to insure it is…

Issue: A retired DoD dependent was mailed medical information of two active duty members. Update: 10/04/12:Two active duty members will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: The ROI Clerks have now been assigned specific printers to print to, and a second party must review the documents prior to mailing them out.