VA Heart of Texas Health Care Network (VISN 17)

Issue: Eleven Compensation and Pension (C&P) files left the Fort Worth Outpatient Clinic but did not make it to their destination, which was Baltimore, MD. Update: 05/20/13:Credit protection services will be offered to 11 Veterans due to the disclosure of their…

Outcome: UPS lost packages...credit monitoring letters sent to protect veterans involved, but no violation found at the facility

Issue: A patient asked for his pending dental appointments and was given another veterans appointment list. The information has been recovered, only one patient was affected Update: 04/30/13:One Patient will be sent a HIPAA notification letter due to Protected Health Information…

Outcome: Employee was provided training and had to retake Privacy Training.

Issue: The Alternate Privacy Officer (PO) received a phone call from Veteran's spouse who reported that she was sent a consent form with an another SSN on the paperwork. All other information pertained to her spouse on the form. She faxed…

Outcome: Alternate PO retrieved the consent form via fax and mail from the Veteran and it was properly destroyed. The employee responsible for entering the incorrect information was re-educated on improperly disclosing PII and required to retake VHA Privacy and HIPPA…

Issue: Veteran A brought in attachments from a letter that was sent to him and told staff that he had received another Veteran's information. Update: 04/22/13:Due to medical information being disclosed, Veteran B will be sent a notification letter06/10/13:This was determined…

Outcome: PO has been informed that department involved in this incident will conduct training addressing Veterans personnel health information.PO has mailed notification letter to Veteran. PO request that ticket 88371 be closed.

Issue: Release of Information inadvertently sent Patient information to the wrong veteran. Patients have exact same name, different addresses. Documents were retrieved and information will be sent to correct veteran/address. Update: 04/19/13:The Veteran whose full SSN and medical information was disclosed…

Outcome: Patient was verbally counseled and re-educated by Supervisor.

Issue: The Patient Advocate received a call from a Veteran who stated that he stopped at the front desk yesterday to ask how to get to Ortho and asked for a print out of his appointments. The volunteer printed out a…

Outcome: Volunteer had to re take privacy awareness training and was educated on how to properly use menu options on VISTA.

Issue: The Patient Representative contacted the Alternate Privacy Officer (PO) reporting that Veteran A received Veteran B's medication in the mail. Veteran A returned the medication to the facility. The PO obtained possession of medication and returned it to the Assistant…

Outcome: The employee that entered the incorrect information has been provided education on the importance of verifying that the correct demographic information is provided to all Veterans. The Alternate PO finds that this was a preventable incident and request that the…

Issue: A Pharmacist handed Veteran A's medications to Veteran B who had the same last name and did not speak good English. Once the error was discovered, the Pharmacy staff immediately contacted Veteran B and the issue was resolved. Update: 03/26/13:Veteran…

Outcome: Staff re-educated.

Issue: A VA Nurse contacted a Veteran's wife and discussed Veteran A's information without obtaining consent from Veteran A. Update: 03/11/13:Veteran A will be sent a HIPAA notification letter.…

Outcome: Employee will be counseled.

Issue: Veteran A came into clinic and 02/26/13 to pick up some copies of his medical records. One of the nurses had given him his copies to take to a local provider. Veteran A later came back for a copy for…

Outcome: PO has mailed a Credit monitoring letter to the Veteran, also AO stated that Training will be conducted to stress the importance of verifying the Veteran before information is released and staff will request identification before releasing information. PO request…