VA Healthcare - VISN 4 (VISN 4)

Issue: Veteran A reported that when he received his standard lab test results data letter he also received in the same envelope the similar lab report test result letters of three (3) other Veterans. The letter is an automated item. Update:…

Outcome: This incident was caused by mechanical error by the machine that folds/stuffs envelopes. Mail Room staff advised to monitor process. HAS and Mail Room notified of error, and to be aware of risk.…

Issue: Patient A and Patient B both had appointments at the Mercer Community Based Outpatient Clinic (CBOC) on 03/16/12. Patient A received his lab work from 03/09/12. Patient A was also given lab work from Patient B, who had lab work…

Outcome: The Privacy Officer will provide a training reminder to CBOC staff on the importance of reviewing all PHI/PII information that is sent out or given to patients or outside providers on the importance of giving out the correct patient information.…

Issue: Veteran A reported that a VA employee (Person A) had given to him a copy of one of his own medical progress notes, which he did not request; note given to Privacy Officer by the Veteran. Person A is in…

Outcome: 4/30/2012 - Credit monitoring letter uploaded. Referred to Human Resources for appropriate action.…

Issue: When preparing paper records for transfer to National Archives and Records Administration (NARA) they were placed in sealed boxes in the corridor adjacent to the Health Information Management Service (HIMS) office. During regular tour after hours VA Police discovered files…

Outcome: 4/2/2012 - Referred to Human Resources/Employee Resources via supervisory chain for appropriate action on 3/21/2012.…

Issue: A Veteran's prescription medication was mailed to the wrong address. Update: 03/20/12:Veteran A will be sent a notification letter.…

Outcome: The Pharmacy address database has been corrected. Training was given to Pharmacy staff regarding entering address changes in the database and double checking the address and patient name before entering them into the database.…

Issue: A telephone call from an attorney 's office on 03/12/12 to the Release of Information (ROI) Supervisor revealed that medical records on Veteran A were sent to their law firm but the medical records were on Veteran B. This was…

Outcome: Medical records employee was reminded on the importance of safeguarding personal identifiable information.

Issue: The registration supervisor reported that Veteran A has been fraudulently using Veteran B's SSN. The report indicates that through the Social Security office it has been verified which name belongs to the SSN, and that it was not Veteran A…

Outcome: The VA police are still investigating this incident and will address any type of potential criminal activity that may have occurred.

Issue: Veteran A received Veteran B's prescription paperwork in the mail. Veteran A returned the documents to VA custody. Update: 03/08/12:Veteran B will be sent a letter of notification.…

Outcome: Staff will be reminded to double check and be aware when choosing names of Script-Pro Equipment list at section staff meeting.

Issue: The Privacy Officer (PO) was notified that VA residents have been requesting Veteran imaging CDs for presentation purposes. The Imaging Supervisor indicated this activity has been occurring for the last few years. The imaging clerks have been providing the VA…

Outcome: OI&T staff assisted the Imaging Department with implementing the redaction capability on the imaging software. The Imaging Department will only provide a de-identified encrypted CD for presentation purposes after a request has been received in writing. In addition, the Imaging…

Issue: Two VA0750 Performance Evaluations forms were added to the OPM folder on employees ending 09/30/11. Both of the employee performance evaluations were scanned incorrectly into the wrong file. The information released incorrectly was full name, Social Security Number, and Performance…

Outcome: Employee staff were reminded on the importance of safeguarding patient personal identification.