VA Healthcare System (VISN 10)

Issue: During his rounds a VA Police Officer discovered an end of shift report that belonged to Unit 5 North. The Officer provided the information to the Information Security Officer (ISO) who delivered it to Privacy Officer. Update: 05/24/11:According to the…

Outcome: Individual was counseled by manager and briefed on the importance of protecting PHI and PII. Individual was also briefed on the policy for taking PHI and PII off campus and the procedures to follow if information is to be transported…

Issue: Veteran A's lab results were mailed to another Veteran in error. Veteran A's full name, SSN, address and lab results were included. Veteran B who received the mailing turned the documents in to the VA. Update: 05/11/11:Veteran A will be…

Outcome: Lab staff educated and reminded to exercise extreme caution when mailing lab results to avoid sending information to unauthorized individuals.

Issue: A patient called a couple of days ago and stated she was going to come in today and pick up her written prescription. The nurse went to the waiting area and called out the patient's name. A lady walked up…

Outcome: VA Police unable to identify person from the surveillance cameras. Staff have been instructed to ask for ID before issuing prescriptions to patients.…

Issue: A Radiology file room employee switched the medical CDs of two (2) Veterans. Veteran A has Veteran B's medical CD and vice versa. The CDs were sent to the incorrect Veterans. Update: 05/05/11:Veterans A and B will be sent letters…

Outcome: PO met with File room and reviewed process for verifying mailing CDROMs. Credit Monitoring letters already provided.

Issue: A patient called VA because they did not receive their medical records that were requested on April 5. The Release of Information clerk who originally took the request verified the address. Update: 05/03/11:The patient will be sent a letter offering…

Outcome: It was determined that the VA was not at fault concerning this incident. This is a USPS issue and the veteran agreed.

Issue: A package containing various documents including patient prescriptions, Means Tests, and other medical record documents were sent to the main Medical Center by a Community Based Outpatient Clinic (CBOC) via UPS. Two days later, the package was returned to the…

Outcome: Although this particular incident could not have been prevented, as it was due to a mishap by UPS while delivering a package containing PHI, the CBOC instituted a new tracking procedure. All scripts en route to the Medical Center are…

Issue: A Community Based Outpatient Clinic (CBOC) Release of Information (ROI) clerk gave a CD containing Patient A's X-Ray films to Patient B by accident. The Supervisor contacted Patient B and Patient B returned the CD. Update: 04/18/11:Patient A will receive…

Outcome: PO Discussed with Rad tech the importance of double checking documents before mailing.

Issue: A Community Based Outpatient Clinic (CBOC) Supervisor inappropriately accessed one of her employee's VISTA (appointment manager) account and electronic medical record. Update: 03/29/11:The employee will be sent a notification letter.…

Outcome: PO provided one on one training and had Supervisor sign a memo reflecting this. Copy forwarded to Service Chief for additional action.

Issue: The Associate Director of a local Veterans Service Organization (VSO) discovered a working copy of a discharge summary for deceased Veteran A in Veteran B's medical records. Veteran B came to the Release of Information (ROI) office to get a…

Outcome: Letter has been sent to next of kin and attached, informing next of kin of the possible breech of information. Training on the proper filing procedures has been performed, to prevent future misfiling of documents.…

Issue: The Privacy Officer (PO) was contacted by a facility employee who said that a patient/Veteran (Veteran A) she was working with today told her that he had received copies of another Veteran's (Veteran B) medical records (cardiology) mixed in with…

Outcome: All staff who release information by virtue of their position have been notified to look carefully at records they are releasing especially at full name and not just last name and other identifiers prior to releasing. Credit monitoring letter mailed…