VA Health Care Upstate New York (VISN 2)

Issue: VA employee discovered spreadsheet with 15 Veteran/patient last names and last 4 SSN unattended in Veteran/patient's room. Update: 01/06/12:It is not known how long the spreadsheet was in the room, however, based on the patients listed it appears to have…

Outcome: VA employee that left information unattended was not identified. Staff members in the vicinity of the incident were notified/educated.…

Issue: The Privacy Officer (PO) was notified by the Patient Centered Care Coordinator that Patient A had given him copies of medical records that he had received in the mail in error on Patient B from the Release of Information (ROI)…

Outcome: HIMS/ROI Supervisor re-educated the ROI clerk on the requirement to confirm the patient's identify before releasing the records. In addition, the HIMS Manager submitted a request to HR for disciplinary action due to previous privacy violations due errors made by…

Issue: Veteran A contacted the Privacy Officer to report that he had received a CD from the Release of Information department with copies of his medical records and when reviewing the CD he found another file labeled with another patient's name.…

Outcome: The HIMS Supervisor re-educated the ROI clerk on the proper procedure for release of records on CD and reporting of inappropriate disclosures resulting in privacy violations. She also submitted a request to Human Resources for disciplinary action due to previous…

Issue: A Veteran signed release for behavioral health notes to go to his Vet Counselor. One progress note contained a Psychiatric diagnosis of alcohol abuse. The release did not cover releasing 7332 information of alcohol abuse. Update: 12/16/11:The Veteran will receive…

Outcome: Employee re-educated about proper procedures to release protected information.

Issue: The Chief of Dental Service reported to the Privacy Officer (PO) that there were 2 occasions where Dental staff inappropriately disclosed patient information in the past week due to failure to observe auditory privacy practices. Specifically, on one occasion, a…

Outcome: Chief of Dental provided verbal counseling to Dental Hygienist and Dental Assistant on required auditory privacy practices.

Issue: Patient A's lab results notification letter was included with information mailed to Patient B. Patient B called to let the facility know that he received information on Patient A. Patient B was asked to destroy the document or bring it…

Outcome: Education provided to staff to take extra caution when stuffing the envelopes with notification letters.

Issue: Upon review of medical record requests where information was withheld requring entry in the Freedom of Information Act (FOIA) FOIAxpress system,the Health Information Management Service (HIMS) Supervisor discovered that a Release Of Information (ROI) clerk had inappropriately released substance abuse…

Outcome: The ROI Clerk was re-educated on the proper procedure to process requests for medical records that include substance abuse information. A request for disciplinary action in the form of a reprimand was also processed through Human Resources and is in…

Issue: On 10/25/11, a Life Insurance company faxed a request and signed release from Veteran A for the last 5 years of medical records. Veteran A then revoked the release in a letter that was faxed to the VA two days…

Outcome: Supervisor and Manager re-educated employee.

Issue: An employee from the Surgery Service accessed a veteran/employee's medical record and disclosed the veteran/employee's imaging test results to him that had been ordered by his Primary Care Provider. at the veteran/employee's request. After receiving the results, the patient then…

Outcome: Employee educated on VA privacy requirements and that he should only be accessing a patient's medical record on need to know basis to do his job, not a coworker's patient record as a courtesy, even if the coworker asked him…

Issue: Outpatient Pharmacy Supervisor notified Privacy Officer a shipping error occurred where two patients meds were mailed incorrectly. Only one had been delivered and the second was intercepted through UPS. Patient A received a prescription through UPS overnight for Patient B.…

Outcome: The Outpatient Pharmacy Supervisor reported that more counter space will be added to the area and Pharmacists will assist in the mail wrapping process to help prevent this from occurring in the future.…