VA Heart of Texas Health Care Network (VISN 17)

Issue: The Assistant Chief of Staff (ACOS) of Ambulatory Care contacted the Privacy Officer (PO) to report that the Fecal Occult Blood Test (FOBT) cards of a Veteran had been delivered to an incorrect address. The intended recipient reported this incident.…

Outcome: This process has been changed where the full SSN is no longer printed on these labels.

Issue: On March 23, 2011, a file clerk at the VHA in Temple, TX mailed a box containing medical files to the Records Center & Vault (RC&V) in Neosho, Missouri. It was delivered by USPS on March 24, 2011. The box…

Outcome: All ROI personnel responsible for shipping records containing PHI/PII have been educated/instructed on not to use UPS provided boxes to ship medical records to the records center or any other location. They all understand what caused this shipping error and…

Issue: VHA staff dropped patient labels on the floor which were turned in. It is unknown at this time who turned in the labels. Update: 03/24/11:Veteran A will be sent a letter offering credit protection services.…

Outcome: Nursing staff to include patient escort staff were re-edcuated. Information will be in a secure envelope when transporting.…

Issue: Veteran A received a fee authorization for Veteran B in the mail at his home. Information disclosed included full name, last 4 of SSN, treatment authorization reason (dental exam), and referring physician name. Update: 03/22/11:Veteran B will be sent a…

Outcome: Fee manager is requiring employee to retake security and awareness training. Employee has been verbally counseled on incident. A privacy notification letter has been sent to the Veteran whose information was compromised.…

Issue: On 11-22-11 an ER provider contacted the Chief Pharmacist to report that while completing the medication reconciliation, the patient stated that they had received another patients medication in the mail. CMOP tracking shows that the medication was delivered to the…

Outcome: The PO educated the staff member about being more cognizant when making changes/correction in the patient files.Warn that these are avoidable privacy violations and will not be allowed.

Issue: Labs and procedure note was faxed to the wrong #, clerk entered all fax numbers correctly except the last one. Individual called and informed clerk he had received the information by mistake. Information was re-faxed to the correct #. Update:…

Outcome: ROI clerk was re-educated

Issue: The Supervisor of the Compensation and Pension section contacted the PO to report that 2 (two) volumes of a veterans C-Files had been delivered on 11-5-10 by UPS to the erroneous address. These files were shipped from Temple VA on…

Outcome: This incident was dicussed by the facillity leasdership with emphasis on the protection of VA sensitive information.

Issue: Patient A received Pt B's appointment letter stapled to his in the same envelope Update: 02/02/11:Veteran B will receive a notification letter.…

Outcome: staff members were re-educated on the proper mailing of documents

Issue: Complainant alleges his electronic medical record was impermissibly accessed by 2 VA employees in February and March of 2010. Filed complaint with HHS/OCR. Update: 04/22/11:The employee will be sent a notification letter.05/02/11:Upon further investigation, the disclosure involved the full SSN,…

Outcome: Disciplinary Action taken against two employees. Veteran/employee received response. HHS/OCR response provided on 1/25/11. HHS/OCR wants this complaint changed to a incident since it was determined that two employees impermissibly accessed their co-worker's electronic health record.…

Issue: A non vet reported that he received a package which was copies of a veteran's record. The letter inside was from UPS, it said that the package torn open, and they repackaged it, but it was not to the veteran…

Outcome: Credit monitoring letter sent