VA Great Lakes Health Care System (VISN 12)

Issue: A Nurse Supervisor found a patient label in the hallway that contained the patient's name and full SSN. The label was dropped outside the Clinic when transferring the patient from one office to the Clinic. It appears at this time…

Outcome: Supervisor of clinic reviewed practice of printing label and determined that it is no longer needed. Supervisor will also remind staff about the importance of safeguarding sensitive patient information.…

Issue: A VA Housekeeper delivered to Privacy Officer a document which was found in outdoor recycle bin, Nurse Supervisor determined who disposed of the information based on handwriting comparison. Update: 07/30/12:It is not known specifically how long the documents were in…

Outcome: Education was provided to the Nurse about the importance of protecting personal information and of the related policies. ISOs recommend this ticket be closed. Thank you. PO provided education to the nurse. Nurses supervisor is considering disciplinary action.…

Issue: A VA employee reported to the Privacy Officer (PO) and the Information Security Officer (ISO) that office employees have had access to her medical record without authorization. Update: 7/20/12:The ISOs interviewed the three individuals identified as possibly unauthorized access to…

Outcome: We are investigating the incident. We have also re-emphasized to the staff the importance of protecting our patients information and only accessing records on a need to know basis.…

Issue: Clinic disclosed Veteran's appointment information to granddaughter over the phone after she was able to provide the Veteran's last four numbers of his SSN. Update: 07/31/12: The Veteran will be sent a notification letter due to PHI disclosed to an…

Outcome: The Clinic manager spoke with the employee about the correct procedure for disclosing information over the phone. Clinic manager spoke with the Veteran about this matter and explained that this was not normal practice in the clinic and that she…

Issue: Veteran A received Veteran B's medication in the mail. Veteran A took all the medication and tried to get it refilled and then realized the medication was supposed to go to his neighbor down the street. Veteran B's name and…

Outcome: Employees will double check prescription name and mailing address name before sending out.

Issue: Housekeeper A delivered a folder of information which was found in the recycle container at the loading dock of Building 135. The folder contained the Veteran's name, full SSN and protected health information. Update: 07/11/12:Veteran A will be sent a…

Outcome: Credit monitoring letters prepared and mailed out.

Issue: The Pharmacy mismailed Veteran A's medication to Veteran B. The responsible Pharmacy staff member selected the wrong address from the drop-down menu in ScriptPro as part of manual data entry used in processing a specified medication. Veteran A and Veteran…

Outcome: Supervisor educated responsible Pharmacy staff member on proper mailing procedures to minimize risk of this mis-mailing occurring in the future. In addition, I instructed the Pharmacy department that, in the future, the VAMC should send a pre-stamped envelope to the…

Issue: Veteran A was mailed a lab report belonging to Veteran B It contained Veteran B's name, full SSN and lab information. Update: 06/29/12:Veteran B will receive a letter offering credit protection services.…

Outcome: Message sent to clerks cautioning them to make sure correct documents are placed in correct patient's envelope.

Issue: Veteran A received Veteran B's Fee Based Care denial letter. Veteran A called the VAMC to report the inappropriate disclosure and that Veteran A had already shredded the material. Update: 06/29/12:Veteran B will be sent a letter of notification.…

Outcome: The supervisor of the employee who mismailed the letter will re-educate the employee on the need to protect Veteran PHI and PII.

Issue: On 06/27/12, the Pharmacy Service at the Oscar G. Johnson VAMC, Iron Mountain, MI received a UPS package containing the Controlled substance II prescriptions from the SS Marie community Based Outpatient Clinic (CBOC). This package was torn into and there…

Outcome: Staff educated on accuracy when sending packages. Police and OIG are aware of situation as there are ongoing issues with medications being handled by UPS. Iron Mountain is looking at changing how we send prescriptions due to continued issues with…