VA Healthcare - VISN 4 (VISN 4)

Issue: On 04/22/13 a Veteran and the Veteran's wife reported that they received medical record information in error. The information was released by VA in error. In addition, the information released was records that VA was maintaining from a fee-based facility.…

Outcome: Education provided to all ROI staff.

Issue: Veteran A came to the VA medical center to pick up a prescription at the pharmacy. Veteran A was given Veteran B's medication. The bag label and prescription bottle had Veteran B information but the paperwork was for Veteran A.…

Outcome: Pharmacy staff were reminded on safeguarding personal health information when dispensing medications. AMG…

Issue: A VA employee printed Veteran information to prepare a case against a VA supervisor. The VA employee redacted the Veteran information and provided copies to service line management and the union. Allegedly, Veteran information can still be seen under the…

Outcome: The employee's computer access was disusered and disabled. A security privacy event violation memo was issued to service line mgt concerning this incident involving this employee.

Issue: Veteran A received a stool card in the mail intended for Veteran B. The card contained Veteran B's name and full SSN. Update: 04/18/13:Veteran B will receive a letter offering credit protection services.05/29/13:This was determined to be HITECH reportable by…

Outcome: Letter of Notification was mailed to Veteran on 5/17/2013. Education was provided to staff involved on 4/17/2013 by Privacy Officer.…

Issue: Veteran A received the correct medication with Veteran B's medication paperwork. Veteran B's name and medication information was disclosed. Update: 04/18/13:Veteran B will receive a HIPAA letter of notification.…

Outcome: A Security Privacy Event Mitigation/Corrective Action Memo was issued to Service Line Mgt. A response is required in 5 business.

Issue: Veteran A's information was released to Veteran B. One of the facility's VA clinicians working at a Community Based Outpatient Clinic (CBOC) provided lab results to the wrong Veteran. Veteran B was contacted by the VA clinician and the clinician…

Outcome: Clinician self-reported incident and was aware to ensure safeguarding of patient health information. AMG…

Issue: Patient A had a Primary Care physician appointment on April 12, 2013. VA staff gave the patient a copy of his lab work. Patient A was given a copy of Patient B's lab work. Patient A took the lab work…

Outcome: SUPERVISOR OF AREA REMINDED STAFF TO CHECK WORK AND CHECK WHAT IS GIVEN OUT TO PATIENTS TO MAKE SURE THE INFORMATTON GIVEN OUT TO A PATIENT IS THEIR INFORMATION. EMPLOYEE THAT CAUSED THIS INCIDENT WAS GIVEN A WRITTEN COUNSELING. THERE…

Issue: Veteran A received medication in the mail. In the package was Veteran B's and C's Medication sheets. Update: 04/09/13:Two Veterans will be sent a HIPAA notification letter.05/28/13:This was determined to be non-HITECH reportable by VHA Privacy Office.…

Outcome: Letter of notification was mailed to Veteran on 5/17/2013. Education was provided to associate involved. Privacy Issue is considered closed at this time.…

Issue: The USPS returned a package which contained approximately 40 pages of medical records of one Veteran. The documents were reported to be found loose in the mail or damaged by mechanical processing by the USPS. Update: 04/08/13:Even thought not the…

Outcome: Records retrieved.

Issue: A VA employee from the Janitorial Service came across patient identifiable information on a Veteran who expired at our medical center. A form was sitting on top of a trash can in an unattended area that is used as a…

Outcome: Care Line supervisor discussed with the individual who accidentally left the personal patient identifiable information in the hallway.Staff was reminded on the importance of safeguarding the information. AMG…