VA Health Care Upstate New York (VISN 2)

Issue: Veteran requested information from an appointment. He received his information but also received a discharge summary from another Veteran. He brought the documents and handed them over to his Social Worker who notified Privacy Officer. Update: 01/16/13:Veteran B will be…

Outcome: Supervisor notified. Employee re-educated on the importance of being careful when taking documents off printer…

Issue: Nurse Manager for the Emergency Department (ED) reported to the Privacy Officer that two patients who were in the ED at the same time received each other's medication lists when given to them in error by the ED physician. The…

Outcome: ED Nurse Manager confirmed that the provider was educated on confirming patient identity before releasing discharge instructions to patients.

Issue: Release of information (ROI) clerk released medical records for deceased individual to daughter. Did not ask if Executor nor confirm she was appropriate Next of Kin. She requested list of providers, He gave her multiple notes and radiology reports. Supervisor…

Outcome: ROI staff appropriately disciplined.

Issue: The Outpatient Pharmacy Supervisor reported that a glucose meter was shipped in error to the wrong patient. The meter was discovered in the Patient A's home unopened by the Home Based Primary Care Nurse who returned it to the pharmacyt.…

Outcome: Outpatient Pharmacy Supervisor counseled the technician regarding the wrong shipping label being placed on the glucomenter and reiterated proper procedure to ensure the correct label is placed. Will also consider a process change with the Pharmacist placing the label after…

Issue: An employee left a message on an answering machine. In the message, the employee never asked the patient to call back to schedule an appointment. She stated that she had reviewed his record and saw that he had an appointment…

Outcome: Education was provided to the employee, as well as a reminder message being sent to all staff regarding leaving messages.

Issue: The Privacy Officer (PO) completed the Quarter 4, FY 12 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: ROI Supervisor notified the ROI clerks of their errors and provided education regarding the requirements to ensure an authorization is HIPPA compliant and allows for the release of 7332-protected information. The privacy violations identified through the ROI audit were also…

Issue: A nurse received a call from the sister of a Veteran and disclosed medical information to the family member without the patient's consent. Update: 11/19/12:The Veteran will be sent a HIPAA notification letter.…

Outcome: Employees were reeducated on proper procedure for discussing information with family and notification letter sent to NOK

Issue: An employee accessed another employee's patient medical record without proper authorization or valid reason. Update: 11/16/12:Employee B will be sent a letter offering credit protection services.…

Outcome: Compliance Officer and Medical Center Director are initiating corrective Action.…

Issue: When Human Resources was reviewing Employee A's OPM electronic file they found Employee B's self identification of disability in the file. This contained Employee B's name, date of birth and SSN. It was in the file for at least several…

Outcome: OPM had scanned document. Local HR deleted it from wrong file.

Issue: Veteran A received Veteran B's medication bottle in the mail for the same prescription. The medication instructions and mailing label for Veteran A were correct. Veteran B's name and medication information was disclosed. Update: 11/28/12:Veteran B will receive a HIPAA…

Outcome: Privacy Officer assessed the incident and provided information regarding proper handling of medication instructions to VA employee.