VA Healthcare - VISN 4 (VISN 4)

Issue: On 02/27/12, an individual from a private business left a voice message that said that he received a fax intended for a home health agency and sent by a physician at the medical center late on 02/24/12. The Privacy Officer…

Outcome: Staff reminded to check fax number vs. number entered, and to verify receipt.

Issue: A Veteran sent a Release of Information (ROI) form via fax with a fax cover sheet from an agency where he was being treated under VA auspices. The Veteran gave conflicting directions to mail records to one address and fax…

Outcome: 2/29/2012 - ROI supervisor counseled employee responsible.…

Issue: VA employee suspects that another VA employee(s) may have accessed his computerized patient record system inappropriately. Update: An access log has been requested from the Information Security Officers. The results of the access log has been reviewed and compared with…

Outcome: The Privacy Officer and Information Security Officer will attend the Service Line staff meeting on March 7th and provide data security and privacy training to all staff.

Issue: A physician was notified after the fact by Patient A that when he was given his discharge Instructions it included the name, DOB & SSN of another person, Patient B. The physician's error was being in Patient B's chart when…

Outcome: Author self-reported; is aware of the basis for Incident. Author changed note title to Error Note, informing subsequent readers of the inaccuracy of the entry. Department staff made aware to avoid future repetitions.…

Issue: Patient A came to the Pharmacy window to pick up his prescriptions. The Pharmacy technician verified Patient A's ID and reviewed the medications, but when retrieving the bag of medications, the Pharmacy technician pulled out a bag of medications for…

Outcome: The Pharmacy technician was reminded of the importance of ensuring that the correct patient gets the correct medications.

Issue: The Pharmacy mailed medication to Veteran A and included in the package medication for Veteran B. Both Veterans were to receive the same medication. Veteran A is returning the medication intended for Veteran B. Update: 02/13/12:Veteran B will be sent…

Outcome: Education was conducted by the Pharmacy.

Issue: Release of Information (ROI) released information to Veteran A from another hospital. In the information Veteran B's information was attached. Veteran A received Veteran B's full SSN, full name, and medical records. Update: 02/10/12:Veteran B will receive a letter offering…

Outcome: Education was given the ROI staff on this issue.

Issue: Veteran A's Release of Information (ROI) request was mailed to Veteran B. This included Veteran A's name, address, full SSN, and protected health information (PHI). Update: 02/10/12:Veteran A will receive a letter offering credit protection services.…

Outcome: Education was given to the ROI staff on this issue.

Issue: A VA Social Worker attended a stand down homeless program for Veterans. The VA station car was in an accident and returned to our VA garage. Personally identifiable information was left in the car. There are non-VA employees - compensated…

Outcome: Employee was reminded to safeguard personal patient identification information especially when off VA government grounds.5 Veterans involved in case - 1 credit monitoring letter attached.

Issue: The Human Resource Specialist disclosed medical information on a Veteran from a VA police report that was completed and submitted to a government agency, the Merit System Protection Board on 2/3/12. Update: 02/07/12:Veteran A will be sent a notification letter.…

Outcome: Employee informed on the importance of securing personal identifiable information.