VA Healthcare - VISN 4 (VISN 4)

Issue: Questionable sensitive record accesses were provided to an employee's supervisor for review. The employee's supervisor determined the accesses were not performed in the course of the employee's assigned job duties. The Veteran is the employee's spouse. The employee alleges the…

Outcome: The employee's computer access has been disusered. A Security Privacy Violation Memo has been issued to the employee's Service Line VP concerning this incident.…

Issue: Veteran A received a fee basis letter documentation in the mail concerning his claim. Veteran's A information was in the envelope along with Veteran B's fee basis letter documentation concerning veteran's name and full address. Veteran A returned documentation to…

Outcome: VA Volunteer that assists in the department was informed on the importance of security and privacy safeguards on personal patient identifiable information.

Issue: A VA employee found a note card on a table in the cafeteria that contained the the handwritten last name and last four of the SSN of five VA patients, also included on the note card was some general clinical…

Outcome: Card was retrieved, clinician that is believed to be the individual who left the card in error was contacted and advised to ensure better safeguarding of this type of information.

Issue: Veteran A received Veteran B's medications at the pharmacy pick up window. Update: 08/02/12:Veteran B will be sent a letter of notification.…

Outcome: The Pharmacy Supervisor reviewed procedures with staff, in which they were counseled to be more careful when batching bags together.

Issue: A form from Release of Information for Veteran A was processed for Veteran B by mistake. Update: 07/30/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: spoke with the ROI clerk on the issue and gave some training on second checking request.

Issue: Veteran A's medication was erroneously given to Veteran B at the Pharmacy window. Update: 07/31/12:Veteran A will be sent a notification letter.NOTE: There were a total of # Mis-Handling incidents this reporting period. Because of repetition, the other # are…

Outcome: As corrective action, the Pharmacy Supervisor reviewed procedures with staff; in which they were counseled to be more careful when batching bags together.

Issue: A patient was brought up from the ward to inpatient surgical unit for a surgical procedure on 7-20-12. The inpatient chart was sent with the patient to the surgical unit but when the Veteran returned to the designated ward unit,…

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

Issue: Non-Veteran A reported that his insurance information was used by VHA to bill for NSC care of a Veteran B. It is known that both Veteran A & B share the same first and last names and dates of birth.…

Outcome: 8/21/2012 - 1) CPAC management aware of need to confirm multiple data points before assigning insurance benefits; 2) CPAC staff, both local and central, to monitor this account; 3) letter send by facility Director to complainant with all information related…

Issue: Veteran A called into the facility and reported that upon discharge was given Veteran B's discharge instructions in error. Veteran A was asked to return the documents to the VA. The discharge instructions contained Veteran B's name, diagnosis and medication…

Outcome: Service line manager will reeducate staff to ensure proper documents are released at discharge

Issue: Veteran A received Veteran B's medication in the mail. The address for Veteran A was accidentally changed by the clinic clerk to Veteran B's address. The medication package was not opened. Veteran B's name and address were the only information…

Outcome: Clerical staff were reminded on the importance of verifying patient information before making demographic changes to a Veteran's medical record.