VA Health Care Upstate New York (VISN 2)

Issue: The Privacy Officer (PO) completed the fourth quarter Release of Information (ROI) audit and identified a total of 15 inappropriate disclosures of Veteran medical records due to invalid authorizations. Two of the inappropriate disclosures included the release of 7332-protected information…

Outcome: HIMS Manager and ROI Supervisor have provided education to the ROI clerks on the proper procedure for ensuring a HIPAA-compliant authorization is in place before releasing PHI and 732-protected information. In addition, written counseling was issued to 2 of the…

Issue: Staff found six wristbands in a locker that had been taken off a ward and was in storage. All six had been patients on the same ward where locker had previously been. Update: 11/08/11:One (1) Patient will be sent a…

Outcome: All furniture is checked before being moved for storage for any PHI PII being left behind.

Issue: Two Veterans were discharged from an inpatient ward by the same RN. Veteran A was given the paperwork of Veteran B by mistake. Veteran B received only his discharge paperwork. Veteran A had problems the next day after discharge and…

Outcome: The supervisor has met with the employee and educated her on the importance of protecting the Veterans information. Credit monitoring letter signed by Director and mailed to Veteran.…

Issue: Volunteer name was on sensitive review by ISO. Questioned supervisor why had accessed an empoyee health file. No response from supervisor. Access suspended. In reviewing what volunteer had accessed it was determined that he had gone into 26 employee health…

Outcome: Volunteer access terminated. Employee health staff sanctioned by HR.

Issue: A VA employee reported that she lost a list of 4 printed Veterans' names with full social security numbers and is unable to locate. Update: 10/28/11:The four Veterans will receive a letter offering credit protection services.…

Outcome: The VA employee has been counseled and retrained by their supervisor in the proper methods of destruction of PHI/PII.

Issue: A daughter of Veteran A talked to a VA employee today. She stated that when her mother (Veteran A) was discharged she was given papers to assist in placement. Included in this paperwork was information on Veteran B. At this…

Outcome: Credit monitoring letter sent out to Veteran. Supervisor educated employee on importance of protecting data in all forms.…

Issue: A staff member made copies of nine wrist bands stapled together. They were used to bypass BCMA and the need for scanning the wristband on the patient. The copies fell out of the staff member's pocket on the floor in…

Outcome: The ISO ran a report to show who had printed the wristbands. The report identified several individuals who were counseled/sanctioned. The Nursing supervisor will monitor the process going forward.

Issue: Patient A's prescription was included in error in the package mailed to Patient B with his prescriptions. This occurred when Patient B's medications were being wrapped by the pharmacy tech for proper mailing via UPS as the medications had been…

Outcome: Outpatient Pharmacy Supervisor addressed the error with the Pharmacy Tech and re-educated the other techs regarding the requirement to confirm patient identifiers when wrapping for mailing to avoid future errors.

Issue: Release of Information form was signed by Veteran A to release medical records to another VA Facility (VA Hudson Valley Medical Center in Montrose). Information to be released included all psychiatric records - all medical records. No 7332 boxes were…

Outcome: Supervisor working with HR department on which discipline action needed.

Issue: Medical Records Collaborative Review sheets for 15 patients were given to the Union by one employee to assist another employee who has filed a grievance. The sheets contain: patient name (all but one have last name, first initial and middle…

Outcome: Education was provided as to how sensitive information should be sent (i.e. using special attention envelopes). Provider voiced understanding.…