VA Healthcare - VISN 4 (VISN 4)

Issue: Paperwork was sent out from our Human Resource (HR) Department to a vendor who is representing a VA employee in an Equal Employment Opportunity (EEO) case. The information disclosed were 2 employee's full names, their full social security number, and…

Outcome: Human Resource staff were reminded on the importance of safeguarding personal patient information.

Issue: Palo Alto Privacy Officer reported a FedEx package sent from a VA Pittsburgh employee containing two Veteran consent forms was never received. This PO is attempting to contact the VA Pittsburgh employee to obtain further details. Update: 05/18/12:The tracking number…

Outcome: The employee has been re-educated about reporting incidents immediately to the Privacy Office and/or Information Security Office.

Issue: TWO PATIENTS CAME INTO OUR Release of Information DEPARTMENT on 4/25/12 AND SIGNED RELEASES. VETERAN A'S INFORMATION WAS SENT TO VETERAN B'S RESIDENCE. VETERAN B RETURNED THE INFROMATION TO THE HIMS SUPERVISOR TODAY. Update: 05/08/12:Veteran A will be sent a…

Outcome: Supervisor of the ROI department reviewed policies and procedures for correctly releasing information to requestors and also the importance of securing PHI/PII.

Issue: An impermissible access of an employee's medical record has been reported. The employee has retained an attorney. A letter from the attorney was received. The attorney is requesting to be informed of what action was taken to resolve the incident.…

Outcome: Employees who inappropriately accessed the Veteran's record read and signed the VA Rules of Behavior. Employees were issued formal disciplinary actions.…

Issue: A clerk was going to copy a Death Certificate and when she hit start on the copier it faxed the Death Certificate to the number that was already in the system. Update: 04/27/12:The Veteran's next of kin will be sent…

Outcome: The staff involved in the incident were educated on the proper faxing practice and to make themselves more aware of what is already on the copier before hiting go.

Issue: A secretary was given information to fax to a outside hospital and entered the incorrect fax number. Update: 04/27/12:The Veteran will be sent a letter offering credit protection services. His full SSN and medical information was faxed incorrectly.…

Outcome: The staff that was responsible was educated on the proper faxing procedure.

Issue: An appointment letter was mismailed due to an error when writing a name and address on the envelope. Update: 04/24/12:One Veteran will be sent a letter of notification.…

Outcome: Supervisor and facility IRT team aware that incident occurred. Employee was re-educated in mail procedures and asked to retake Privacy and HIPAA training as part of that education.…

Issue: Veteran A reported to the Community Based Outpatient Clinic (CBOC) that he received a letter that contained Veteran B's document along with his. The letter was in regards to a new electronic payment requirement form that was recently sent out.…

Outcome: The mis-mailed letter was recovered. This letter pertains to a mass mail out that was sent out recently. With the use of computer automated equipment it is believed that this was an isolated incident involving the envelope stuffing procedure. There…

Issue: Patient had a Compensation and Pension Exam on 4/3/12. It appears the examiner printed an old C&P exam from 2009. The exam was accidently printed to a non clinical area of the carpenter shop, it sat on the printer at…

Outcome: The Behavioral Health Executive will be conducting training with staff on the importance of printing material to the correction printer. If there are IT problems with printers not being routed correctly. They should contact Information Systems to correct the problems.

Issue: Patient A's appointment letter was mailed to Patient B. Patient B called into VA to inform staff of the incident. The Privacy Officer (PO) is making arrangements to pick up the information from Patient B. The information compromised included Patient…

Outcome: Will work with department leaders to have them to be more aware of mailing information out to Veterans and the consequences of mailing incorrect information to the wrong Veteran. The method of training will be up to the department leaders.