VA Healthcare System (VISN 10)

Issue: VA employee (nurse) inappropriately accessed the medical record of a patient without a legitimate need to know on three occasions. Update: 12/21/12:Patient A will be sent a notification letter.…

Outcome: VA employee (nurse) accessed the electronic medical record of a patient possibly without a legitimate need on three occasions.After reviewing privacy violation and obtaining an access record report on the Veteran/patient, it was confirmed that employee accessed the medical record…

Issue: The Georgetown Community Based Outpatient Clinic (CBOC) faxed documents to Spintech Ventures, Xenia, OH. This company has no association with the VHA. Update: 12/17/12:Spintech is not a HIPAA covered entity. One patient will be sent a letter offering credit protection…

Outcome: Training was provided to the Georgetown administrator on the importance of ensuring faxes are faxed to the correct place.

Issue: A Veteran contacted the Patient Advocate and told her that while he was at lunch on 11/16/12, a physician came over to his table and told the Veteran who was eating with him that he had cancer. This was the…

Outcome: The Supervisor of physician met with her and took appropriate action.

Issue: Fee Remittance Advice (3 pages) was mailed from VISN/Facility Fee Department to a patient listed on the Remittance Advice rather than the contracted Home Health Agency as intended. Veteran/patient received Remittance Advice and gave to Home Health Agency employee when…

Outcome: We contacted the Fee department who handles the mailings to have them explain their process of sending out correspondence. We made sure that they understood to double and triple check their envelopes before sealing and placing them in the outgoing…

Issue: A Clerk at a Community Based Outpatient Clinic (CBOC) received a call from Veteran A, stating that he received a specimen container in the mail via UPS. Veteran A collected the specimen and was preparing to send it back when…

Outcome: Process for mailing lab specimen cups is currently being evaluated and revised to prevent similar incidents from occurring in the future.

Issue: A physician completed a physical capacities evaluation form for a Veteran's attorney without obtaining signed authorization from the Veteran. Update: 11/21/12:Veteran A will be sent a letter offering credit protection services.…

Outcome: EDUCATION PROVIDED TO PHYSICIAN TO SEND ALL REQUESTS FOR INFORMATION TO THE RELEASE OF INFORMATIONOFFICE FOR PROCESSING.

Issue: A 30 day Medical Certificate form was completed by a physician for a Veteran and faxed to the utility company without signed authorization. Update: 11/07/12:Veteran A will be sent a notification letter.…

Outcome: Staff provided education on need for patient authorization prior to sending forms to third parties.

Issue: A Veteran (A) reported receiving in the mail two Veterans' (B and C) lab result letters. The Veteran came to the hospital and returned the letters. Update: 11/05/12:Veterans B and C will be sent letters offering credit protection services, as…

Outcome: Briefed staff on the importance of properly mailing out patient information, ensure you double check envelope has proper patient information prior to sealing.

Issue: Employee/Veteran stated supervisor was added to medical documentation to sign off on as a co-signer. Update: 11/14/12:The Employee/Veteran will receive a letter of notification.…

Outcome: PO spoke to all parties involved and found that a privacy violation existed. Head of department stated that would work with HR and Chief/Asst Chief to put a policy in place concerning situations such as this one.

Issue: Lab staff at this Medical Center sent specimens and anatomic forms to another VA via courier. The specimens arrived at the VA, but not the anatomic lab forms, which contained full patient name, full SSN and diagnosis. This is the…

Outcome: CHANGE IN POLICY REPORTS ARE NO LONGER SENT SEPARATELY; ARE NOW INCLUDED INSIDE SPECIMEN CONTAINERS BEFORE PICKED UP BY COURIER.…