VA Health Care Upstate New York (VISN 2)

Issue: An ER Nurse Manager reported to the Privacy Officer that Patient A received his discharge instructions this morning from his ER physician that had Patient B's identification label on it in error. The identification label had Patient B's full name,…

Outcome: Emergency Room attending physician educated ER provider on requirement to confirm patient identifiers before placing label on discharge instruction sheet.

Issue: Privacy Officer identified during the course of the quarter 3 release of information audit that protected health information of 4 veterans was inappropriately disclosed when requested from a 3rd party requester and processed by the ROI clerks. The inappropriate disclosures…

Outcome: Two of the clerks who were fairly new to release of information were re-educated on the proper procedure for screening of 7332-protected information reminded of the requirement to forward to the HIMS Supervisor for review and redaction once identified. The…

Issue: The Privacy Officer found an Ophthalmology Progress Note and a letter to the patient regarding his upcoming pre-operative clearance appointment in the eye clinic left out on a table in a conference room, which was unlocked and unattended. It is…

Outcome: VA privacy policy was reviewed with all of the Residents at our Friday am meeting. In addition, the Resident Physician who inadvertently left the information in the conference room was counseled, and the Residency Program Director of Ophthalmology notified.…

Issue: Veteran A's medication bottle was given to Veteran B by mistake. Update: 08/16/11:Veteran A will be sent a notification letter due to PHI being disclosed.…

Outcome: Staff education provided.

Issue: BVAC employee received anonymous letter as per below. Only received copies of the notes, not the original. I am a veteran and a veteran advocate who gets his medical care at the VA on Westfall Road. I have been provided…

Outcome: Staff education provided.

Issue: During an interview panel an employee was asked to refer to a time when they were able to hand off work to another employee or department. The person being interviewed referred to a former employee/Veteran who uses our facility for…

Outcome: Notification letter sent to Veteran/employee. Education conducted and HR action initiated with employee.…

Issue: Outpatient Pharmacy Supervisor reported to Privacy Officer that Patient A's ferrous sulfate order was mailed to a Patient B in error. This was mailed with the patients order in error, bottle only without paperwork, therefore only the Patient A's name…

Outcome: Outpatient Pharmacy Supervisor reminded staff about the requirements of keeping the order slips in order to prevent future errors.

Issue: The Buffalo Regional Office (RO) Information Security Officer (ISO) notified the Syracuse VAMC ISOs and Privacy Officer (PO) that a claims file (C-file) sent from the Buffalo RO could not be found at the Syracuse VA. After further review, it…

Outcome: Business Office has improved their tracking process of the C-FIles from point of receipt to point of return from the VBA Regional Office to strengthen controls on the location of the C-Files.

Issue: Veteran A (who happens to be an employee at the Bath VA Medical Center) received discharge instructions intended for Veteran B. This document was mailed from the Buffalo VA Medical Center. The envelope was hand-written. Veteran A brought the document…

Outcome: Staff have been re-educated on privacy and process to verify that the correct information is put into the correct envelopes.

Issue: While reviewing daily Sensitive Record Access logs, it was determined that a few employees within the Syracuse VAMC access a deceased patients medical record without the need to know. Update: 05/24/11:The Veteran's Next of Kin will be sent a notification…

Outcome: Supevisor have submitted names to HR for disciplinary action in the form of a reprimand.