VA Heart of Texas Health Care Network (VISN 17)

Issue: After requesting information from the Release of Information section, Veteran A reported that they had received the medical information of Veteran B in the mail. Veteran A reported that Veteran B lived close to his address and that he personally…

Outcome: The PO identified the ROI employees who processed the information and forwarded in error and determined that both incidents were preventable. The PO discussed with the employees both individually, attended the ROI Staff Meeting and addressed with all staff members,…

Issue: Veteran A presented to Medical Administration Service (MAS) Staff to check in for a procedure, VA employee A from MAS placed the wrong Patient ID Band on Veteran A that contained another Veteran's Full name, SSN and DOB. Veteran A…

Outcome: Credit monitoring Letter send out. The Clinic AO will be conducting training for all staff on the importance of reviewing all documentation prior to handling it to a Veteran, stressing the importance of safe guarding Veteran information.

Issue: A contract lab company notified our lab dept that the specimens of 16 patients had not arrived. The tracking shows that it was picked up by the mail carrier, but the contract lab had not received it. The labels included…

Outcome: Letters mailed to those included in this breach. This was a case where the packages left here (picked up by mail courier) - no corrective action applicable in this case.…

Issue: Pharmacy Service reported medications were sent to the wrong patient, same first name, same last four. The medications were sent from the CMOP, however the audit trail shows the address was changed on the wrong patient. The address was corrected…

Outcome: Staff re-educated.

Issue: Veteran A received a letter in the mail addressed to him although the Fee Authorization contained within the letter belonged to Veteran B. The Fee Authorization contained Veteran B Full name, last four, home address, date of birth, and condition…

Outcome: Chief of MAS has informed me that training will be conducted on a monthly basis to educate on the importance of previewing all vouchers before they are sent out for mailing. Protection of personal health information will be discussed at…

Issue: A patient asked for a copy of his labs, when he reviewed them over the weekend, he realized it was on a different patient with the same last name. The patient returned the information to the Privacy Officer. Update: 10/29/12:Patient…

Outcome: CBOC staff re-educated.

Issue: It was reported that while walking in her neighborhood, 54 CDs and 5 EKG reports were found in a one block area. The CDs were labeled with the patient's name, and some included the DOBs, SSNs, ward, physician, etc. The…

Outcome: All staff reminded to go through the proper channels when there is a need to transport PHI from a controlled environment...otherwise, taking PHI off station is prohibited.Notification letters sent to those involved.

Issue: While visiting with Veteran A, the VISN Veteran Advocate identified information belonging to Veteran B was intermingled in information that had been received by Veteran A. This was two progress notes containing the full name, SSN, address, DOB and lab…

Outcome: Credit Letter mailed to Veteran. Service chiefs have been informed that their areas must practice quality control methods to ensure that the mailing contains the correct information.…

Issue: After requesting and receiving an access report, the employee/Veteran is requesting a justification for the accessing of the record by another employee. Update: 12/07/12:The Privacy Officer (PO) determined that one incident of access could not be validated in regards to…

Outcome: PO determined that one incident of access could not be validated in regards to Treatment, Payment or Healthcare Operations. The investigation results will be forwarded to the Chief Of Staff with the recommendation to contact HR to address the appropriate…

Issue: Veteran A arrived at the front desk to check in, it was around 3:42pm, he stated that the clerk was rude to him, handed him a printout containing Veteran B's info to include full name, full SSN DOB, home address,…

Outcome: MAS Supervisor has informed me that she will be conducting training for all MAS staff on the importance of reviewing all documentation prior to handling it to the patient, also will ensure that employees are aware of what location they…