VA Great Lakes Health Care System (VISN 12)

Issue: The spouse of Veteran A stated that she found some papers on the Veteran's bedside table and brought them home with her. The papers are the Nutrition Supplement Listing for 16 Veterans on one of the wings of the VA…

Outcome: The supervisor of the responsible employee was made aware of this incident and will take appropriate supervisory action. In addition, the supervisor is working on a new process to minimize the use of paper lists to prevent this sort of…

Issue: A VA employee reported that she was missing diskettes with patient information such as name and last 4 digits of the SSN. The employee reported it to VA Police. The Information Security Officer (ISO) will update when more information is…

Outcome: Employee found the missing diskettes, also credit monitoring was offer to the 4 individuals affected. New section rounding policy and procedure established. Training provide to staff. Credit monitoring letters prepared.…

Issue: VAMC Pharmacy inadvertently mailed the medication for Veteran A to Veteran B. Veteran B promptly returned the mis-mailed medications to the VAMC Pharmacy for proper disposal. Veteran A's name, last four digits of the SSN and medication information was compromised.…

Outcome: Supervisor was notified of the improper mailing and will take appropriate supervisory action.

Issue: A military dependent received a one page document containing medical information on an active duty member. the information on the active duty member included the name, full SSN and diagnosis. Update: 09/19/12:A military dependent requested her records from Release of…

Outcome: Employees educated and policies have been changed.

Issue: A PM nursing assistant found a list of 9A dietary snack supplements in the mens public restroom next to the elevator. The list contained 66 patients' name, room number and last 4 digits of the SSN. After speaking to a…

Outcome: Notification Letters were sent out this morning. The Nursing Supervisor and the Supervisor of the Dietary employees were notified of this incident and will send out a reminder to all their employees about the importance of safeguarding sensitive information. In…

Issue: Veteran A received VA Form 10-5345 ( Request For and Authorization To Release Medical Records) in the mail from the VAMC. Included on the form was Veteran B's full name and the last four digits of Veteran B's Social Security…

Outcome: Supervisor was made aware of situation and will provide additional training/awareness to staff on importance of checking documents mailed out from the VAMC.

Issue: A VA employee accessed another VA employee's medical record. The Tomah Information Security Officer (ISO) disabled the LAN and Vista accounts of the employee who was in the medical record until further investigating has been conducted. Update: 08/06/12:The patient will…

Outcome: Offender's computer access has been removed. HR & Director's office is conducting investigation.

Issue: Veteran A was mailed some documents from the VAMC and Veteran B's consultation sheet was included in the envelope to Veteran A. Update: 08/02/12:Veteran B will be sent a letter offering credit protection services due to full name and SSN…

Outcome: Supervisor of responsible office was notified of mis-mailing and is educating staff on procedures to protect patient's confidentiality.

Issue: A non-VA employee called the LaCrosse Community Based Outpatient Clinic (CBOC) stating she had a Veteran's health information and she brought the bag into the LaCrosse CBOC. It is believed the information had been in the bag at the apartment…

Outcome: Medical records have been recoverd by Tomah VA Privacy Officer. The PII was received back at the facility and destroyed. The individual who took the medical records off site hasn't worked here since 2008. I have educated staff on the…

Issue: I inspected a unit that was recently vacated for relocation and found two veterans records. One is a Medical Record containing progress notes, full name, full SSN and DOB, the other containing full name and address. Update: 07/31/12:One Veteran will…

Outcome: The responsible supervisor of the unit was informed about this incident and educated.