VA Great Lakes Health Care System (VISN 12)

Issue: The Wausau Community-Based Outpatient Clinics (CBOC) received a call from Veteran A stating that he had received a lab result letter in the mail for Veteran B and wondering what he should do. An envelope was mailed to him so…

Outcome: Staff were educated on making sure that they must check all mailings.

Issue: Veteran A called stating that he received x-ray results for Veteran B. Update: 02/13/12:Veteran B will be sent a notification letter. No SSN or date of birth were disclosed.…

Outcome: The envelope preparation machine has been serviced and there are now manual checks of the envelopes that are sent out to Veterans.

Issue: Patient A was referred for fee basis care and Patient's A medical records were forwarded to the outside provider without 7332 information being redacted. Update: 02/10/12:Veteran A will recive a letter of notificatoin.…

Outcome: Fee staff have been reminded to review for 7332 info when processing process authorization requests and what to do in the event 7332 info is found. In addition the process for releasing medical records for fee basis requests is under…

Issue: Mental health patient reported he got another patient's appointment letter in the mail. Veteran destroyed the letter. Update: 02/07/12:Veteran B will be sent a notification letter.…

Outcome: Staff were educated on accuracy when mailing.

Issue: The Facility Information Security Officer (ISO) was notified by the Tomah Information Security Officer that a Health Insurance Portability and Accountability Act (HIPAA) violation had occurred due to actions by the Human Resources Division (HR) at the Milwaukee facility. Milwaukee…

Outcome: ISO was informed that the HR specialist who made the error has been counseled and the veteran in question has been provided credit monitoring.

Issue: Veteran A called into the Patient Advocate today after receiving Veteran B's mail from the VA. The document was discharge instructions. It included the patient's name and educational information regarding his recent urgent care visit. No other identifying information was…

Outcome: Education was provided to staff to assure that when mailing out information they need to make sure that letters aren't double stuffed. After receiving the documents back from the patient who received it in error, the document was discharge instructions…

Issue: Patient A received his own discharge summary and Veteran B's summary upon discharge from an outpatient clinic on 12/02/11. Patient A brought Veteran B's paperwork to a patient advocate upon his next visit to the hospital. Update: 12/20/11:Veteran B will…

Outcome: Reviewed with staff proper procedures for discharging patients. Staff reminded to review all documents before they are handed to the Veteran. Handoff process being reviewed as well as other factors (# pts being d/c, lack of staff) to discover whether…

Issue: Patient A's wife contacted the OIG to advise that her husband's record under the registration information contained the name and full SSN of a minor child of a Patient B. Patient A had received the name and SSN of the…

Outcome: This ticket can be closed. Veteran has been notified and the ID Analytics team is reviewing.…

Issue: An employee sent a Preliminary Fee Remittance Advice Report to Veteran A which also contained information for Veteran B. Veteran A contacted Social Work to return the information. Update: 11/29/11:Veteran B will be sent a notification letter due to name…

Outcome: Fee basis staff have been re-educated on proper procedure for mailing of Veteran information and reminded to check pt info before mailing to ensure it is being sent to the correct individual. Staff reminded of potential consequences for Veteran with…

Issue: A Tomah employee accessed her son's medical record without authorization. Update: 11/29/11:Patient A (the son) will be sent a notification letter due to PHI being accessed without authorization.…

Outcome: Offender was counseled by supervisor and educated on not accessing records without authorization.