VA Healthcare System (VISN 10)

Issue: During a Halloween party on one of the long term care, nursing units, a staff member took pictures of staff andpatients then posted them on Facebook. The Supervisor asked that the pictures be immediately removed from Facebook - which they…

Outcome: Staff educated into proper use of cameras on ward. Notification letters sent to patients.…

Issue: A nurse mis-faxed a letter to a private citizen's home on one patient instead of to a doctor's office. The private citizen faxed the information back stating they received in error. The letter contained the patient's name, DOB and full…

Outcome: Credit monitoring letter Sent. Employee self reported error, no further action as employee is aware of the requirements.…

Issue: Veteran A called to inform that he had received Veteran B's lab results the mail. The document included Veteran B's name, full SSN and protected health information. Update: 10/26/11:Due to full SSN being exposed, Veteran B will be sent a…

Outcome: Personnel have been retrained on the importance of ensuring documents going into envelopes are double checked prior to sealing and mailing out.

Issue: A Release of Information (ROI) staff person inadvertently released an appointment roster with 65 Veterans' information to another Veteran. The information that was disclosed included the Veterans' full names, full social security numbers and telephone numbers. Update: 10/25/11:Sixty-three (63) Veterans…

Outcome: Letters to Veterans were signed on 11/22/11 by the Director and mailed out on 11/25/11. The ROI Staff person stated that she was not sure of how to retrieve the type of report that the Veteran requested and pulled up…

Issue: Audiology Chief did speak with individual that handed wrong handbook to Veteran and reiterated that the employee ensure that they did not give a Veteran items or paperwork with another Veterans information.. Veteran A did confirm that he had it…

Outcome: Audiology Chief did speak with individual that handed wrong handbook to Veteran and reiterated that the employee ensure that they did not give a Veteran items or paperwork with another Veterans information.

Issue: A neurologist found an end of shift report at 5:30 pm on 10/3/11, unsecured in the VA cafeteria. The report was printed at 2:56 pm on 10/3/11, so the window it may have been unattended is from 3:00 pm-5:30 pm.…

Outcome: Nurse Supervisor reminded all staff to secure documents and not to take documents outside the office.

Issue: An eligibility clerk had a stack of 5 Veteran applications on her desk. She turned the papers over so that the Veteran, whom she was meeting with, could not see names and other information. When she was finished meeting with…

Outcome: Employee was reprimanded. Copy of Credit Monitoring letters are attached.…

Issue: A medical doctor from United Health Group mailed Veteran A's Medical Records consisting of 200 pages through the United States Postal Service (USPS) via Priority Mail to the Cincinnati Medical Center for scanning into the Veteran Record. According to the…

Outcome: No corrective actions taken, since this occurred at the United States Postal Service. Credit monitoring letter has been sent to Veteran.…

Issue: The AFGE Secretary sent a Leave Donation request via Outlook email to local staff. The email included the fact that requestor had PTSD. The Associate Director informed and the email was recalled. Update: 08/15/11:The employee will be sent a letter…

Outcome: Local president, AFGE, counseled sender of message and it was recalled. ISO advised all users to delete message from all baskets. Notification letter was mailed to employee.…

Issue: A Prospect List, used for outreach, was found with three Veterans' first and last names, last four of their SSNs, phone numbers, service branches and dates of service. The list was found unattended and face up on the display booth…

Outcome: Outreach Supervisory educated staff on properly handling and safeguarding of Veteran information.