VA Healthcare - VISN 4 (VISN 4)

Issue: Veteran A enrolled for health care at the medical center. The clerk placed Veteran A's demographic information into Veteran B's record. When Veteran B reported for a scheduled outpatient appointment and the clerk was verifying the demographic information with Veteran…

Outcome: Enrollment staff were reminded on the importance of safeguarding patient health information and reviewing computer information. AMG

Issue: The USPS returned a one page document which they reported to be found loose in the mail or damaged by mechanical processing. The document was one page of a Veteran's medical record. It cannot be verified that this document was…

Outcome: Record retrieved.

Issue: A Release of Information (ROI) clerk was checking on the status of a UPS package sent that contained a copy of a Veteran A's medical records. UPS reported that the package is lost as per the tracking number and not…

Outcome: Credit monitoring document has been sent.

Issue: Privacy and Release of Information (ROI) regulations state that a VA health care facility can report a Veteran to the State Department of Motor Vehicles if the patient's driving would be a serious threat to the health and safety of…

Outcome: Supervisor for the Release of Information department was reminded to review privacy regulations on sensitive information before releasing this type of information.

Issue: On EOC Rounds on 3/27/13, Bldg. 2 was reviewed. In Room 217 of Bldg. 2. A covered folder was located that contained Protected Health Information/Personally Identifiable Information (PHI/PII) information. It was on a desk behind a curtain and on the…

Outcome: The use of the folder that caused this privacy violation has been eliminated. Electronic secured spreadsheet will be used in its place. They will no longer use the location of this privacy incident also. The clinic is moving to a…

Issue: On EOC Rounds on 3/27/13, Bldg. 2 was reviewed. In the basement of building two (no room number) in a room that contained ceramic and recreation information a card file was found that contained information: Patient Name, Last four of…

Outcome: The PO and Program Manager of the area involved took the card file and destroyed it per Sensitive Record Destruction Policy. It was an old card file. Staff were also reminded to be aware of what information is laying around…

Issue: While conducting EOC rounds the PO found 4 documents laying on a desk in an unlocked and unoccupied room. The 4 documents contained PII and were dated about 1 year ago. It appears that these documents were left from the…

Outcome: The PO will continue to monitor unoccupied spaces and educate staff about proper safeguarding of sensitive VA information

Issue: Information was faxed to a private businessman by a VA staff member. The staff member didn't doublecheck the fax number and was trying to fax it to a private local hospital. Update: 03/26/13:It is unknown what the documents are but…

Outcome: Still have not received any contact from businessman who received the information. Promotion code letters were sent to the two Veterans involved.

Issue: Veteran A was mistakenly mailed Veteran B's diagnosis. Update: 03/19/13:Veteran B will be sent a letter offering credit protection services.…

Outcome: The provider who mistakenly sent the information to the wrong Veteran was counseled and instructed to check information before mailing for accuracy.

Issue: Patient A received a package addressed to Patient A with the correct paperwork but the medication bottle was labeled for Patient B. Both Patients A and B had prescriptions for the same medication, same dosage, and same quantity. This occurred…

Outcome: Patient A received a package addressed to Patient A with the correct paperwork but the medication bottle was labeled for Patient B. Both Patients A and B had prescriptions for the same medication, same dosage, and same quantity. This occurred…