VA Health Care Upstate New York (VISN 2)

Issue: An employee from the Field Office was contacted by a VA employee. Her personnel health folder was sent to him but not requested. He contacted said employee and mailed her folder to her. She brought it to the attention of…

Outcome: HR and Personnel Health have to change their process for pulling records of people no longer employed and HR sending records to other facilities.

Issue: Patient A and Patient B were sent each others insulin. After it was investigated by the Outpatient Pharmacist Supervisor, it was discovered the medication coolers were addressed prior to the medication being checked by the Pharmacist. The Technician packed the…

Outcome: The Outpatient Pharmacist has educated the technicians and Pharmacists regarding the new requirement to have the Pharmacist check the completed prescription including the shipping cooler to verify patient identifiers before mailing.

Issue: The Privacy Officer (PO) completed the Quarter 1, FY 13 Release of Information audit and identified personally identifiable information (PII), protected health information (PHI) and 7332-protected information that was released to outside third parties (insurance companies, attorneys, non-VA providers, and…

Outcome: The Health Information Management Service (HIMS) Manager was reviewed the errors with the ROI staff and re-educated them on the requirements of a HIPAA compliant authorization as well as how to properly screen for the presence of 7332-protected information.

Issue: The Privacy Officer (PO) received a call from the Nurse Manager (NM) of 6 East today regarding a patient that they discharged this morning. NM stated that there was a privacy incident that occurred when a staff nurse was delivering…

Outcome: Nurse Manager educated nurse on process of placing any patient paper documents face down when being interrupted to assist a patient as a reasonable safeguard.

Issue: While in employee A's Electronic personnel file, it was noted two other employee's Life Insurance Election form were scanned into employee A's file. Human Resources printed copies to put in the correct employee's files and deleted from wrong employee file.…

Outcome: Items removed from wrong file and scanned to correct employee.…

Issue: An employee health staff member accessed four sensitive electronic medical records, of four Veterans with the same last name, attempting to find the correct sensitive electronic medical record of an employee of the Western New York Healthcare System. Update: 02/08/13:Four…

Outcome: Employee has been reeducated and has retaken the TMS courses "Privacy and HIPAA" and "VA Privacy and Information Security Awareness and Rules of Behavior."

Issue: IT Specialist reported to the Privacy Officer that he found a Nursing End of Shift report on the ground of the off-site employee parking lot when leaving work for the day. He secured the information until bringing the report to…

Outcome: Nurse Manager re-educated all nursing staff of the requirement to place the End of Shift Nursing Note in the shredding bin at the end of the day to ensure it is properly secured and destroyed. Recommendation to remove the patient's…

Issue: Copies of a Veteran's medical record were mailed to the wrong person. The person who received them knew one of the authors of a note and contacted her. The staff member then retrieved the records from the wrong recipient and…

Outcome: ROI staff educated on addressing envelopes properly.

Issue: A Veteran claims that a family member has been calling requesting information on him. He states someone at the VA had to have told her that he was being treated here. Update: 03/07/13:Per the Privacy Officer (PO), the Veteran's sister…

Outcome: Education for staff.

Issue: Patient A reported to the Medical Center Director's Office that he had received Patient B's medication reconciliation summary report when being discharged from the Emergency Department on 12/31/12. He turned in the copy he received in error to the Director's…

Outcome: Nurse Manager educated the provider on the requirement to confirm the patient identifiers (name) before releasing the medication reconciliation report to the patient.