VA Healthcare - VISN 4 (VISN 4)

Issue: An individual from the general public erroneously received a fax from VA containing Veteran information. The individual is agreeable to returning the documents to VA custody. Update: 01/22/13:PO waiting for the information to be returned before determining what information was…

Outcome: Service Line Mgt met with the VA employee to discuss the issue, review the proper procedures and verbalized understanding of the error. The VA employee reviewed the TMS information and policy for further clarification. Additionally, the other two CHN staff…

Issue: The Human Resources staff who conduct new employee orientation have lost a new employee's in-processing package of Official Personnel Folder documents. The package contained various employee documents, including name, full SSN, date of birth, financial information, and work history information.…

Outcome: HR staff will evaluate the new employee process to minimize the likelihood of this issue occurring again.

Issue: Veteran A called into VA Butler Healthcare and talked to the Privacy Officer. Veteran A had received Veteran B's audiology report from a recent audiology appointment. Veteran A shredded the Audio report. The PO investigated where the report was sent…

Outcome: PO and Supervisors of ROI reviewed procedures of the ROI department and stressed the importance of double checking work before sending it out. Reminded them of the importance of protecting veteran health information

Issue: Patient A received the correct medication in the mail and the package was addressed correctly. But, Patient A also receive another package addressed to him containing a prescription for the same medication but it was for Patient B. Patient A…

Outcome: Employee was reminded on the importance of safeguarding personal patient identifiable information.

Issue: A VA Provider accidently gave a patient his appointment list instead of his discharge paperwork. Update: 01/10/13:There were 7 patients' information on the appointment list, including the patient to whom the list was given. The list contained the patients' name,…

Outcome: Education was given to the provider on double checking information before handing it to a patient.

Issue: A domiciliary patient filed a complaint that staff is releasing patient information to the parole office without authorization. Update: 01/14/13:After an investigation the improper disclosure did happen. The patient will be sent a HIPAA notification letter.…

Outcome: Whenever VA staff release information to a patients Parole Officer, they are required to contain an authorization from the patient. If it contains 38 U.S.C. 7332 it must have the extra consent marked. Veterans was admitted to our Domiciliary Program…

Issue: Patient A received his medications in the mail. In the envelope was Patient B's medication Information Sheets, including his full name, address and medication list. Update: 01/07/13:Patient B will receive a HIPAA letter of notification.…

Outcome: The pharmacy staff was educated on the correct procedure for mailing medications.

Issue: On 11/1/12, a sensitive record access log was generated at VA Pittsburgh for routine monitoring and auditing. Two accesses by a VA Clarksburg employee were identified as questionable. The access log was provided to the Clarksburg Information Security Officer (ISO)…

Outcome: The Privacy Officer spoke with the employee about this incident. He stated that his brother called him and asked if his appointment had been made in Pittsburgh and the employee was looking to see if it had been made. I…

Issue: A VA employee faxed a Veteran's discharge summary to the wrong fax number. The recepient contacted VA and reported the issue. Update: 12/26/12:One Veteran will be sent a letter offering credit protection services due to full name and SSN being…

Outcome: Service Line Managment was notified and this performance measure will be addressed with the employee

Issue: A Veteran received an employee's reminder letter in the mail. The Veteran reported this incident to the VA. Update: 12/21/12:Employee/Veteran B will be sent a notification letter.…

Outcome: Service Line Mgt corrective action is as follows:This is an old format appointment letter. It is dated 11/30/12. If this letter was processed in the mail room, it is possible that our automated folder/stuffer machine inserted two letters in one…