VA Healthcare - VISN 4 (VISN 4)

Issue: Veteran A received Veteran B's medication sheet via mail the sheet included full name, full SSN, DOB, and listing of medications of Veteran B. Update: 06/28/11:Veteran B will receive a letter offering credit protection services.…

Outcome: The Veteran was not registered with the Erie VAMC but was registered through the Pittsburgh VAMC. Pittsburgh was notified of the mis-mailing and will follow through with re-educating staff in mail procedures.…

Issue: Vetsnet Compensation and Pension Award form from Station of Jurisdiction: Philadelphia (310) was mis-mailed to another Veterans fiance on June 3, 2011. She mailed it to the Veteran who is an inpatient at Coatesville VA Medical Center. Veteran Received mail…

Outcome: Letter offering credit protection services sent, employees re-educated.

Issue: Patient A's information was mailed to Patient B by the Release of Information (ROI) department. The information is being retrieved by VA employees today. They are going to the patient's home. Please note that the patient had a complaint entered…

Outcome: The Supervisor for the area will review the specified release process and review the Privacy Violations Reporting System.

Issue: A research and development study clinical coordinator reported an unanticipated problem that affected 18 study subjects. It was reported that the names, addresses, SSN's and phone numbers of 18 study subjects were faxed to the affiliate university for the purpose…

Outcome: The research compliance officer is working with the IRB to ensure this type of process is properly reviewed and that any type of payment functions that require the submission of PII to an outside entity is properly indicated in the…

Issue: The Research & Development department submitted an Unanticipated Problem to the Privacy Office involving two (2) study subjects.Study subject A was sent a letter that contained a check which contained study subject B's name and address.Study subject B received a…

Outcome: The research staff has also implemented an improved quality assurance process that will help to minimize the likelihood of this type of error occurring in the future.

Issue: Veteran A received Veteran B's accounts receivable bill in the mail. The bill included Veteran B's medical information. Update: 06/01/11:Veteran B will be sent a notification letter.…

Outcome: The MCCF/Billing Supervisor is rectifying the Veterans' billing accounts.

Issue: A custom script was faxed to the outpatient department on 12/17/10. On Environment of Care (EOC) rounds 06/01/11, the script was found in a plastic container outside of Exam Room 3 in the outpatient department. It has probably been there…

Outcome: Nurse supervisor will provide reeducation to staff involved on the importance of patient confidentiality. Will also look at their procedures to determine if they can correct possible privacy lapses not just in this area but other areas as well

Issue: An employee of a CBOC gave medical information over the phone regarding three Veterans. This disclosure was not authorized. The employee no longer works for the CBOC. Update: 06/01/11:The three Veterans will be sent letters of notification.…

Outcome: The CBOC employee was terminated by the Contracted Agency prior to this investigation. The Management Services Officer for the CBOCs sent all VA Pittsburgh CBOCS a copy of the current Privacy Policy at this Privacy Officer's request; informed there is…

Issue: An address label and a Personally Identifiable Information (PII) label for Veteran A were switched and the PII label was attached to the outside of the envelop and sent to the Post Office for mailing. The PII label contained the…

Outcome: Reeducation was done with staff involved. Reminded them of the importance of patient privacy and to be careful when mailing information to patients. Double check the make sure the label is correct and the information inside the envelope is for…

Issue: Document scanning cover sheet and medical imaging report for one Veteran were left on a printer in an open area. The VAMC is under construction and employees are being moved to various areas. Someone printed information to the printer and…

Outcome: The PHI and PII information that was left on the printer was printed from staff swing offices. Staff use these offices when their offices are under construction for various reasons. An email message was sent to all staff that use…