VA Healthcare System (VISN 10)

Issue: The Chief of Canteen Service brought to the ISO two U.S. Government Messenger Envelopes containing two (2) incident reports and one (1) Encounter Action Required Report . The two incident reports contain full name, full SSN, and DOB for two…

Outcome: Mental Health Care Line Manager counseled employee as to the appropriate methods of securing patient information.

Issue: The VA Travel clerk mistakedly gave Veteran A a document pertaining to Veteran B. Update: 07/27/11:Due to name, full SSN, and DOB being exposed, Veteran B will be sent a letter offering credit protection services.…

Outcome: Travel Clerk inadvertently gave Veteran a document pertaining to another Veteran. Travel clerk scanned Veteran's ID (without picture) into the system and another Veteran's name and information came up. After investigating this incident it was determined that the clerk did…

Issue: Employee mistakenly put two letters in the same veteran's envelope. The letter was printed from CPRS (progress note) and stated:"This clerk received lab letter from Team Provider. Letter will be mailed out this date". No diagnostic information was included.When veteran…

Outcome: CREDIT MONITORING OFFERED TO PATIENT. STAFF EDUCATED IN IMPORTANCE OF PROPER MAIL HANDLING TO PREVENT UNAUTHORIZEDDISCLOSURE OF PHI.…

Issue: Veteran A's appointment schedule was sent or released to Veteran B. The appointment schedule contained Veteran A's name, address and diagnosis. Update: 07/25/11:Veteran A will receive a letter of notification.…

Outcome: Reminded staff to be aware of what information they were releasing to Veterans and ensure it was the correct information.

Issue: A VA LPN accessed her husband's medical record. The nurse is an intermittent employee who works on an occasional basis. The nursing supervisor has been informed. Update: 07/20/11:Since it is unknown if spouse had verbal permission (policy violation), Veteran A…

Outcome: Associate Director for patient Care has counseled employee. Notification letter was sent to Veteran.…

Issue: Employee is social worker who travels with VA patient information in brief case. Vehicle was left unlocked Tuesday containing patients advance directive in briefcase, in car. Items were not there on Wednesday. Employee reported today. Update: 07/15/11:The social worker believes…

Outcome: The local policy addressing the transportation of phi off-station was provided to employee and to his Supervisor. Supervisor met with employee to address incident and to provide counseling. Credit monitoring offered to Veteran involved in privacy breach.…

Issue: An Employee found an unsecured Employee personnel folder behind the nurses' station. The folder was in a high traffic area where other employees could have viewed the employee's personal information, past performance evals, SSN, DOB, home address, court documentation, etc.…

Outcome: Spoke with Nurse Manager. This file was misplaced during the move. We covered the entire area looking for any additional unsecured information and did not find any. Since this was a onetime move, I can't offer any additional recommendations besides…

Issue: During Environment of Care (EOC) rounds of government vehicles, the unsigned draft of treatment plan for Patient A was found in a vehicle used for outreach. The treatment plan was found face up on a clipboard in the passengers seat.…

Outcome: Supervisor of outreach program was notified and verbalized that the department has plenty of secure bags to transport patient information during outreach. Supervisor was going to speak with employee.…

Issue: Copies of Veteran A's lab work were inadvertently mailed to Veteran B with the same last name. When this information was received in the mail, Veteran B reported the incident to his physician. The lab work was discarded by Veteran…

Outcome: LAB STAFF REMINDED OF THE IMPORTANCE OF MAKING SURE THAT TEST RESULTS ARE SENT TO THE CORRECT PATIENT TO PREVENTOPPORTUNITIES FOR IDENTITY THEFT.…

Issue: The Release of information (ROI) clerk released a Certificate of Medical Necessity forms for a glucometer and testing supplies from the Pharmacy for Veteran A to Veteran B. The forms contained Veteran A's full name, address, DOB, Phone number, diabetic…

Outcome: ROI clerk was reminded of the policies to check all information before releasing to the Veteran. Employee understood wrong-doing and re-training of how to safely handle PHI/PII.…