VA Great Lakes Health Care System (VISN 12)

Issue: Veteran A called and stated that she received Veteran's B Fee Claim summary. Veteran A stated she would send Veteran B's information back to the VAMC today. Not clear at this time what information is in the mis-mailed document or…

Outcome: No way of tracking who the responsible employee is, so the supervisor of the employees who are handling the mailings verbally instructed the employees to take care when mailing the Fee Claim letters and to ensure that they make sure…

Issue: A VA patient's Lab summary was found outside in parking lot. It contained the patient's name, last four digits of the SSN and the lab results. Update: 06/13/12:Patient A will be sent a notification letter.…

Outcome: We have re-educated staff about leaving patient information unattended.

Issue: Patient A received Patient B's information in the mail. Update: 06/07/12:Patient B will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: Credit monitoring letter mailed and employee's supervisors contacted for appropriate action and education of their employees.

Issue: Veteran A reported that he received the medication refill document of Veteran B with the same last name. Veteran A reported that he shredded Veteran B's paperwork that contained the Veteran B's name, home address and medication information. Update: 06/06/12:Veteran…

Outcome: Education provided to employee to be more attentive when mailing documents.

Issue: A VA RN was supposed to send Veteran A a copy of his lab results. The RN allegedly also included confidential information about Veteran B. Veteran A immediately brought the mis-mailed information back to the VAMC. Update: 05/31/12:The information was…

Outcome: Supervisor of the VA RN was notified of this inappropriate disclosure and education was provided to make sure that only the correct documents are mailed to our Veterans.

Issue: A Veteran requested through secure messaging (SM) a referral to a specialty clinic. Nurse case manager who responded via phone left a message with a family member who answered. This message consisted of the phone requirements Veteran would have to…

Outcome: Clinic staff have been reminded of the acceptable use of PHI in phone messages and re-educated on the use of patient sensitive information, ensuring that specific clinic information is not discussed unless the Veteran has authorized it.

Issue: A new Release of Information (ROI) employee missed a 7332 item when preparing records to send to an attorney. Item should have been redacted as release Veteran signed did not specify 7332 disclosure. Update: 05/29/12:The Veteran will be sent a…

Outcome: Employee received re-education on 7332 information- what it is and how to review records to ensure it is not disclosed without Veteran permission.

Issue: Veteran A received his own and Veteran B's information in the mail. Veteran B's name, full SSN, and protected health information (PHI) was compromised. Update: 05/30/12:Veteran B will be sent a letter offering credit protection services due to full name…

Outcome: Employee will go through papers to make sure no other Veterans information is mixed in with another Veterans information before giving to Veteran.

Issue: Veteran filled out VA Form 10-5345 to release certain medical records to an adoption agency. The Release Of Information staff member over-released to agency, including records that exceeded the scope of the authorization. Update: 05/24/12:The Release of Information office sent…

Outcome: Supervisor was made aware of the inappropriate disclosure. The ROI staff member was provided education and reminded of the importance to disclose only that information permitted in the authorization.…

Issue: A Department of Defense (DoD) provider copied and pasted medical information from the DoD AHLTA record of Patient A into the CPRS medical record of Patient B. The provider is listed as a DoD provider, however, the DoD provider inappropriately…

Outcome: Provider discontinued practice of copy and pasting notes. Credit monitoring letter mailed.…