VA Healthcare System (VISN 10)

Issue: Veteran A contacted the lab in writing stating that he not only received his lab results but also those of Veteran B. The lab results belonging to Veteran B were returned to the lab along with the letter. Update: 01/30/13:Due…

Outcome: A change in the mail policy was implemented at the CBOC to prevent similar incidents from occurring in the future. Nurse responsible for mis-mailing called Veteran to apologize.…

Issue: The Community Outpatient Services (COPS) Nurse stated Veteran A received Veteran B's lab results. The COPS Nurse spoke to an Information security Officer (ISO) before contacting the Privacy Officer (PO) and stated the ISO told them to tell Veteran A…

Outcome: Notification Letter was mailed and uploaded. Employees were counseled on 2/1/2013.

Issue: Employee called to state a Nurse called her about her Uncle. Her uncle is a VA Patient. The Nurse is not part of treatment team and Employee believes the Nurse accessed the record inappropriately. Entered into PVTS late (admin oversight)…

Outcome: Redacted Notification letter uploaded. Original mailed on 2-11013. Copy of findings given to Supervisor for appropriate personnel action.

Issue: The printed progress notes of two (2) Veterans were found on a printer in unlocked, common area. The time stamp on papers say that it was printed 12/11/12 and 12/12/12. The documents were found by the IT specialist when the…

Outcome: Credit Monitoring letters mailed on 1-30-13. PO performed walk through of Warehouse to ensure no additional data was found.

Issue: Inpatient roster with name of attending physician highlighted at top of page was found on a busy elevator used by the public. The Roster contained the names, last 4, age, admission date, today inpatient days of stay, ward, room and…

Outcome: Although I was unable to identify who left the phi on the elevator, I asked staff in the area to be vigilant and to immediately report any cases of unsecured phi.…

Issue: Psychologist called to state one of her employees verbally disclosed information on a patient to the Maple Heights Police Department. Psychologist is writing up a report of contact. No authorization or legal authority exists per Psychologist. Update: 2/6/13:The Privacy Officer,…

Outcome: Copy of Report of Contact and supporting evidence sent to the Supervisor for corrective action. Redacted letter uploaded, notification letter mailed on 2-8-13 to patient.

Issue: Physician complained that a nurse who called a patient to schedule an appointment with the physician involved told them (patient and wife) that the physician was pregnant and would be going on leave any day as a result of the…

Outcome: Had already counseled employee involved before change to notification letter. Notification completed, signed by Acting Director and delivered. SAL/PO…

Issue: Patient was in media on 8-24-12. Patient received access log that reflect 8 individuals accessed his record on 8-24. Patient was last seen 8-7-12 and not again until 9-4-12. Patient request a total of 14 individuals access be reviewed. A…

Outcome: Redacted notification letter uploaded. Original to be picked up by patient. Copy of findings sent to each supervisor for corrective action. Email to PCAS Supervisor to address updating SOP on travel procedures. Email to Nurse Manager to better define processes.

Issue: A VA clerk in the Release of Information (ROI) section processed a request for Veteran A. The documents that were released included a Vitals Management Report (2 pages) for Veteran B. When Veteran A realized that he accidentally received a…

Outcome: Staff were reminded to slow down and to double-check all copies released in the Release of Information Section to make sure that allcopies belong to the Veteran making the request.

Issue: Call forwarded to the Privacy Officer (PO) by PBS Secretary. Veteran A stated that in the mail that he received today, he received not only his lab work, but that of Veteran B. The documentation included the Veteran B's full…

Outcome: Information shared with Supervisor of area where information was released. Employees will be asked to be more careful when mailing test results to make sure that information pertaining to more than one Veteran doesn't get mailed out in the same…