VA Healthcare - VISN 4 (VISN 4)

Issue: The Ears, Nose and Throat (ENT) Clinic Manager reported to the VA Police and the Privacy Officer (PO) that an unlocked/unsecured file cabinet in an unsecured area had been tampered with. The file cabinet stored documents containing protected health information…

Outcome: The credit protection letters were provided to the affected individuals. The area where the incident occurred has been properly secured and improved safeguard measures are in the process of being implemented. The file cabinet was rekeyed by the locksmith and…

Issue: The Information Security Officer (ISO) received a call from an employee at Pine Richland Trucking Company indicating that they received a fax containing one (1) Veteran's lab data. On the fax was the Veteran's full name, full SSN and DOB…

Outcome: Instructed the sender to verify fax numbers prior to faxing any documents and to check the number entered on the fax machine before hitting send.

Issue: The Community Based outpatient Clinic (CBOC) Administrator reported that Veteran A called and indicated that he had been given an appointment list for Veteran B. Veteran A stated that he would send it back to the CBOC and asked for…

Outcome: The credit protection letter was sent. Staff will be re-educated about better quality assurance at the next staff meeting.

Issue: VA Supervisor found a Veteran's check-out/medical facility worksheet tacked on a message board in the hallway by the VA Canteen. Update: 10/19/11:One Veteran will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: Response received from the Service Line Mgt, in which they are pursuing a Clinic Order Set in CPRS instead of using the hard copy check-out sheet. The PO was informed that by using this option all information will be kept…

Issue: Two inpatients went on pass on 09/23/11. The pharmacy delivered both sets of pass medication to the floor on 09/23/11. Veteran A was sent home with his medications but one medication of Veteran B's was sent along with him. The…

Outcome: Pharmacy staff was re-trained on the importance of ensuring accuracy when dispensing medication.

Issue: Upon discharge from the hospital, Patient A was given the printed Discharge Instructions of Patient B. Patient A reported to the nurse who made the routine post-discharge call to Patient A. Update: 10/05/11: Patient B will be sent a letter…

Outcome: Communicated issue to involved staff via chain of command. Privacy Officer provided item specific training and awareness to staff involved. Credit given to reported nurse who identified the issue.…

Issue: A Physician at one of the contracted Community Based Outpatient Clinics (CBOC) sent in a substance use form to the Pennsylvania Department of Transportation informing them that they thought the patient was incompetent to operate a motor vehicle. The form…

Outcome: TRAINING TO STAFF AT THE CRANBEERY CBOC WAS COMPLETED. AS WELL AS A REMINDER TO ALL STAFF.

Issue: The Supervisor from the Radiology department reported to the Privacy Office that a copy of CD containing images was given to Veteran A for a medical visit with an non- VA, fee basis provider. The CD that was given to…

Outcome: Cd was returned, employee was reeducated about better quality assurance of radiology Cd's.

Issue: On 9-16-2011 a request for ROI was processed on two separate patients. The medical record information on both patients was inadvertently placed together and mailed to one of the two requester's. The patient who received his and the information on…

Outcome: Training was provided to the employee. Double check everything that is being mailed to ensure that the documents are going to the correct addresses. Based on the current staffing in this area there is the need to work at a…

Issue: Veteran A and veteran B each made independent Release Of Information requests for medical records. In error A received the records of Veteran B. Veteran A reported by phone that he will return misdirected records to medical center ROI department.…

Outcome: Employee counseled and action taken within chain of command.