VA Healthcare System (VISN 10)

Issue: Employee A was contacted by Veteran A, indicating that upon receipt of information requested from VA it appeared that another Veteran's information was also included. Update: 10/02/12:Two (2) Veterans will be sent a letter offering credit protection services due to…

Outcome: Records for two patients were retrieved by VA facility from patient who reported receiving them in error. Staff involved has been counseled. A checklist to use when mailing and faxing sensitive information provided and reviewed.…

Issue: Veteran A reported that he received in the mail from a Veteran B a box from the VA, and in the box was all of (his) Veteran A 's personal information containing: name, address, phone number, date of birth and…

Outcome: After a thorough review of the privacy complaint the following findings were discovered: The chief of the department from which the box was mailed stated the box was advertently mailed out by a former employee who has retired. Mailing information…

Issue: Release of Information Clerk accidentally faxed lab work and ultrasound to the wrong phone number. Recipient of information called the AOD to notify him of this incident. AOD reported it to me, the PO. AOD advised recipient of info. to…

Outcome: EMPLOYEE EDUCATED ON IMPORTANCE OF VERIFYING FAX NUMBERS BEFORE SENDING PHI.

Issue: Four (4) patients' names and full SSNs were on forms sent to Cincinnati VAMC that Cincinnati reported they did not receive. The forms were sent with patient samples. The samples were received in Cincinnati in a cooler by a contract…

Outcome: Spoke with Lab Manager. No clear evidence can be shown establishing whether forms were actually mailed. Emphasized the need to leave a better document trail. Lab reported a change in procedure. Reports will now be mailed in the same container…

Issue: Release of Information Clerk prepared a CD for a veteran, containing his medical records. On this disk, the clerk added 50 pages of another Veteran's medical record, that she obtained from the VISTA Imaging Software. These 50 documents included EKGs,…

Outcome: Employees reminded to double-check all paper copies of records and CDs before mailing to make sure that they contain only information pertaining to that specific Veteran.

Issue: A Patient brought in a mailing he received at home that contained various billing communication forms (letter, Verification of Medical Expensed Form, Statement of Medical Care Cost Recovery Form, Disable American Veterans form) on 4 different other veterans. None of…

Outcome: Checklists for reviewing documents for mailing and faxing information (from HHS/OCR) have been provided to various areas that frequently mail and fax, e.g., ROI, billing, pharmacy, Director's Office; staff are asked to review and use to help prevent these occurrences.

Issue: Veteran and Cincinnati VHA employee is reporting unauthorized access into his medical records via CPRS and/or VISTA by another VA employee (co-worker). Update: 10/18/12:This ticket has been changed to an incident. The investigation showed that the employee did in fact…

Outcome: Credit monitoring sent to Veteran. Employee had access to CPRS removed (Aug 14, 2012) until her retirement today and Letter was placed in her HR file.…

Issue: A Patient reported that someone created a My HealtheVet account for him (June 2012). The Patient stated that he did not create the account. Update: 08/20/12:It was confirmed that two clerks were authenticating Veterans without obtaining their authorization. They stated…

Outcome: VACO MHV letters mailed this morning to patients. Processes were changed and education was given to all ROI and CBOC clerks by the VISN My HealtheVet coordinator.

Issue: An appointment letter was mailed to an incorrect Veteran. The letter contained the full Veteran name, address and diagnosis. The Veteran that received the letter gave it to his daughter, a VA employee, to return it to the sender. Update:…

Outcome: Individual responsible for mailing incorrect information could not be identified. Process will be reviewed for vulnerabilities.…

Issue: Facility management notified the acting Privacy Officer that they had received a phone call from Veteran A (a family member), who indicated that they were notified by Veteran B by letter that Veteran A's information was mailed to them to…

Outcome: Scanning staff counseled on checking each page of any multiple page scanning "jobs". Credit monitoring letter sent to patient. SAL/PO…