VA Healthcare System (VISN 10)

Issue: Patient A received an appointment reminder for another patient, Patient B. Sent by the Community Based Outpatient Clinic (CBOC). Update: 03/14/11:The appointment letter contained the appointment information, name, and address. Patient B will receive a notification letter.…

Outcome: Patient Record coded to prevent future mis-mailing. There are two patients with same last name and same last 4. System error.

Issue: Employee A mailed Employee B a "thank you" card. Employee B stated they do not know how Employee A received their home address. Update: 02/15/11:Veteran B will receive a notification letter.…

Outcome: Employee was educated by PO concerning the protocol for distributing mail.

Issue: Laboratory specimen with lab slip was lost during transport from patient care unit to laboratory. Update: 02/14/11:The lab slip included the Veteran's full name, full social security number, and date of birth. The Veteran will be sent an offer for…

Outcome: After investigation it could not be determine how the lab work was lost. An email is sent to all staff involved to safeguard the transporting of lab work within and on facility groundsThis is closed.…

Issue: patient (former SW intern) received a DRG Security log and reported 3 individuals in SW service that accessed her Medical Records. Update: 02/23/11:Patient A will receive a letter offering credit protection services.…

Outcome: Po gave 1 on 1 training to SW and had sign a memo. Copy given to to Service Chief and referred for any additional action.…

Issue: Employee accessed a veteran's CPRS record without just cause. This employee had been counseled in the past to not access veteran's medical record; however did not comply.Veteran requested a list of all staff who accessed his medical record and identified…

Outcome: Disciplinary action currently being addressed by employee's supervisor and Human Resource Service. Credit Monitoring Letter mailed to Veteran on February 16, 2011. Recommend that this incident be closed.…

Issue: Patient A received Patient B discharge summary. Patient B was contacted by the patient representative to ensure they received the correct discharge summary. Patient representative contacted Patient A and stated Patient B did not receive their discharge summary. Update: 02/16/11:Veteran…

Outcome: During my interview with the employee I educated them on how to prevent this type of situation from happening. Also I informed them of reporting incidents such as this one to the Privacy Officer. They were also informed that it…

Issue: Employee A in charge of passing out W-2s to their service gave Employee B the wrong W-2. Employee B didn't notice until over the weekend and opened the W-2 noticing then that it was not theirs. Employee B brought the…

Outcome: Credit Monitoring letter provided to employee.

Issue: Provider verbally disclosed to Patient A's roomate protected health information regarding his MST group. Both patients were inpatients at the time. Update: 02/09/11:Veteran B will receive a notification letter.…

Outcome: Notification letter mailed. Provider educated during meeting with PO.

Issue: A patient received 161 pages of another veterans medical records from Release of Information. Patient brought the documents back to the Privacy Officer. Name, SSN, and PHI were released. Update: 01/05/11:Veteran will receive a letter offering credit protection services.…

Outcome: PO provided one on one training with clerk and reviewed her processes. Supervisor gave counseling to employee.

Issue: VA employee reported that she suspected a co-worker had accessed her record to retrieve her date of birth. Privacy Officer ran a Record Audit report and it confirmed that the suspected co-worker had accessed the employee's record. Update: 01/04/11:Employee will…

Outcome: After investigation the individual is found in violation, further investigation determined that another individual accessed the employee's record with no legitimate need to know. Administrative action is pending regarding these individuals with supervisor and Human Resources. Credit Monitoring letter approved,…