VA Heart of Texas Health Care Network (VISN 17)

Issue: Employee A was reviewing a medication list that was issued to Veteran A by Employee B and noticed that this list did not belong to Veteran A but should have been issued to Veteran B. The medication list listed his…

Outcome: Immediate Supervisor and AO of facility was contacted regarding incident. Supervisor has made contact with employee regarding re education and retraining. Employee is to retake TMS training and provide certificate to Alt. PO. Notification letter has been submitted to Veteran…

Issue: A Medical Adminisntration Service clerk faxed a Release of Information request to an incorrect fax number. The fax included the Veteran's full SSN and first name, Update: 09/30/11:The Veteran will receive a letter offering credit protection services.…

Outcome: Process at clinic has been changed, so that only the ROI clerk will send requests for medical information for Veterans. MAS clerk who misfaxed information has been instructed by supervisor to retake privacy and information security training. Credit monitoring letter…

Issue: The Alternate Privacy Officer was conducting Privacy rounds and came across an unsecured office space containing multiple documents with unsecured protected health information (PHI) on the employee's desk, cabinet above her desk and table behind her desk. The documents contained…

Outcome: The immediate supervisor and Department Chief both counseled the employee which included education, retraining and awareness plus re-signing of the Rules of Behavior agreement.

Issue: A Physician Assistant forwarded an encrypted message with an attached spreadsheet to a large mail group that contained the names, last four of the SSN and home telephone numbers of nine patients with a positive alcohol screen. The provider also…

Outcome: The PO met with the employee. She was provided details on the disclosure of information protected under 38 U.S.C 7332. The PO determined this incident to be an unauthorized disclosure of protected health information and requested that the Service Chief…

Issue: Veteran A reported to the Patient Advocate that she did not realize that a clinic clerk had provided her with the sensitive information of 2 (two) other Veterans until she arrived home from her clinic appointment. She volunteered and has…

Outcome: The PO could not identify the exact source of the disclosure at the clinic location. The PO met with the supervisor of the section and provided instruction on the importance of clerical staff reviewing information prior to disclosing to Veterans.…

Issue: A list containing the full names SSNs, and diagnoses was in a binder that was mistaken for trash, and picked up by housekeeping staff. The service was unable to retrieve the book. Update: 08/25/11:It has been determined that there were…

Outcome: Credit monitoring letters were sent to the Veterans involved in this incident. Staff was provided education. Converting to electronic systems.…

Issue: A VA patient called to report that a list of names and SSNs of other patients was included with his information. Update: 08/30/11:There were forty-five 45 patients' name and full SSNs disclosed. Therefore 45 patients will receive a letter offering…

Outcome: PO and Clinical manager counseled MD to ensure patient is given only his information. Credit monitoring letters sent.…

Issue: Veteran A did not receive his medications via mail. The Veteran called the Pharmacy to follow up on his medications and it was revealed that his medications were delivered to the wrong address. The address that was listed in the…

Outcome: Inquiry sent to Chief of MAS to follow up and see that all patients demographics are up to date in the system by her staff by providing retraining/reeducation on the importance of correct pt data in the system.

Issue: Patient A received Patient B's medication mailed from the Outpatient Pharmacy. Update: 08/04/11:Patient B will be sent a notification letter, due to his name and medication being disclosed improperly.…

Outcome: all NCFC pharmacy staff were re-educated

Issue: Patient Representative received a call this morning from the wife of Patient A. Patient A had a medical issue yesterday 7-20-11 and came back into the Emergency Room (ER) last night. Patient A was treated and released. This morning the…

Outcome: The entire department received education on the importance of validating patient identity. Written counseling for the employee was recommended by the Supervisor. HR is currently involved with the corrective action recommendation.