VA Healthcare - VISN 4 (VISN 4)

Issue: While processing a Release of Information (ROI) request, the incorrect patient was chosen and information was sent to the attorney requesting the information. The attorney's office contacted us upon receipt of the information and stated that they shredded the information…

Outcome: Educated the clerk.

Issue: In the course of providing an evidence file in matter of a recently dismissed employee, local HR staff included a Report of Investigation that included confidential information of seventeen (17) employees. The dismissed employee informed his former co-workers that he…

Outcome: 1/9/2012 - Supervisor provided verbal counselling to employee.…

Issue: Veteran A was given the surgical discharge instructions that were intended for Veteran B. The discharge instructions contained Veteran B's name, full SSN, date of birth, and protected health information (PHI). Update: 01/04/12:Veteran B will be sent a letter offering…

Outcome: The document was retrieved by the Privacy Officer. The credit protection letter was given to Veteran B. Education was provided to the OR staff by the Privacy Officer.…

Issue: A prescription for Veteran A was filled correctly on 12/07/11. It was a refrigerated medication and it was packed and mailed from the medical center on 12/08/11 by UPS. In the packing process, the pharmacy technician selected an incorrect patient…

Outcome: Pharmacy staff were reminded on the importance of ensuring accurate patient identification when filling medications.

Issue: Veteran A received Veteran B's medication at the pharmacy outpatient window. Update: 12/20/11:Veteran B will be sent a notification letter, as his name and medications were disclosed.…

Outcome: The pharmacy staff was educated on this issue.

Issue: A driver was sent to Veteran A's address due to another Privacy issue and when the other privacy information was received this additional document was also given to the Privacy Officer. The Veteran received this information when he picked up…

Outcome: A supervisor in the pharmacy department educated the staff on this issue and went over what happened and how they should check each printed slip before placing in the slips into a medication pick-up bag.

Issue: A patient received discharge instructions after surgery procedure and copy of Schedule of Operations was included in error. Update: 12/09/11:The list contained the patients name, SSN and diagnosis and type of surgery for 16 patients. Letters will be sent offering…

Outcome: The Privacy Officer spoke to the nurse who discharged the patient and let him know about the incident. Supervisor was notified.…

Issue: A user reported to the ISO that a story on her was published at www.va.gov/womenvet. The story contained photo of her which contained her full ssn. Update: 11/21/11:The employee will be sent a letter offering credit protection services.…

Outcome: Picture was pulled from the website. National office was made aware of the incident. Credit monitoring offered.…

Issue: Veteran A received Veteran B's radiology report in the mail, which included Veteran B's full SSN, DOB, and medical information. Update: 11/17/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: A SPE Memo has been sent to Service Line Management concerning corrective action with this issue. At this time, there is pending disciplinary action for the employee involved with the clerical error.…

Issue: Veteran A was seen in the outpatient clinic. When he checked out of the clinic he was given medical record data on Veteran B. He stopped at the beneficiary travel window and realized he had medical record information on Veteran…

Outcome: Fact finding was performed and we were unable to find how Veteran A obtained Veteran B's medical information. However, we performed training with allnecessary staff in the outpatient clinic to remind staff on the handling of personable identifiable information.…