VA Healthcare System (VISN 10)

Issue: A VA employee inappropriately accessed her spouse's medical record who is a Veteran and employee, to retrieve medication information. Update: 03/18/13:Veteran/Employee B will be sent a notification letter.…

Outcome: Access Record Report confirmed that employee did access spouse's electronic medical record twice on the same day. The employee was required to complete a privacy questionnaire where she admitted to accessing spouse's record. The employee stated she accessed spouse's record…

Issue: Two Means Test Anniversary Letters for different patients went into one envelope and were sent to Patient A. Patient A returned the erroneously mailed Means Test Letter to his RN when she made her next homecare visit. The RN gave…

Outcome: Volunteers who stuff the envelopes with these letters were again reminded to ensure they've only got one document for each envelope so as to avoid sending multiple patient's information to the same address.

Issue: Veteran A received a two-sided lab letter with Veteran B's lab results on the opposite side. Veteran A brought the lab letter back to the Community Based Outpatient Clinic (CBOC). Veteran B's name and lab results were compromised. Update: 03/13/13:Veteran…

Outcome: Administrative Staff was counseled by CBOC Supervisor.

Issue: A VA employee notified the Information Security Officer (ISO) that when logging into VA-PAS in order to update his contact information, the address, occupation series code, occupation series, type of appointment information associated with his profile were not his information.…

Outcome: See Activity for 5/1/13. No action to be taken as error did not originate with this facility. ISO reported the incident up the chain to program office: VA-PAS. SAL/PO…

Issue: A Clerk at a Community Based Outpatient Clinic (CBOC) allowed a Veteran's wife to sign VA Form 10-5345a to obtain a copy of her husband's medical records. The wife had no legal authority to sign for the Veteran. Update: 03/12/13:Veteran…

Outcome: EMPLOYEE WAS EDUCATED IN THE IMPORTANCE OF OBTAINING CORRECT AUTHORIZATION BEFORE RELEASING PHI. QUESTIONS SHOULD BE FORWARDED TO THE PRIVACY OFFICER OR ALTERNATE.…

Issue: Nurse intended to fax documents to a local medical office; however, they were mistakenly faxed to a John Deere dealership in Georgia. Recipient shredded documents once he notified the VA. Update: 03/08/13:The patient will be sent a letter offering credit…

Outcome: EMPLOYEE EDUCATED ON PROPER USE OF FAX MACHINE - PARTICULARY WITH REGARD TO CORRECT ENTY OF DIGITS FOR OUTSIDE LINE AND AREA CODE.REQUEST THAT THIS TICKET BE CLOSED

Issue: Employee accessed the electronic medical record of a co-worker without a legitimate need. Update: 02/27/13:The co-worker will receive a HIPAA letter of notification.…

Outcome: After thoroughly investigating the violation it is confirmed that employee inappropriately accessed co-worker's electronic medical record without a legitimate need, according to an Access Record Report that was retrieved. A meeting was held with employee and he was opened about…

Issue: Veteran A called and said that he received Veteran B's appointment letter in the mail. According to the clerk who mailed the letter, the address in the computer was entered incorrectly resulting in the letter being sent to the wrong…

Outcome: COMPUTER UPDATED TO REFLECT CORRECT ADDRESSES OF BOTH VETERANS INVOLVED.

Issue: The Release of Information (ROI) clerk processed a request for a Veteran, but handed this Veteran the records of a second Veteran that the ROI clerk had just recently completed another request on. The first Veteran noticed that he had…

Outcome: ROI employees were counseled on proper procedures to double-check all documentation before providing it to patients, especially after obtaining information from printers/copiers.

Issue: An employee reported that he found his W-2 earnings form laying in the Staff locker room of the inpatient unit that he is assigned to. The W-2 was lying on the heater in the room and the room is accessed…

Outcome: RN Manager advised to change procedure currently followed with regard to distributing payroll and income tax information to avoid similar incidents from occurring in the future.…