VA Heart of Texas Health Care Network (VISN 17)

Issue: A VA Provider attempted to contact a patient concerning his test results. The patient was not at home. The Provider informed the patient's wife of positive tests results which were sensitive in nature. Update: 07/27/12:The investigation concluded the provider did…

Outcome: Provider was counseled and re-educated on training.

Issue: A Release of Information (ROI) clerk processed a release of information request and forwarded the incorrect information to both Veterans. The information consisted of 26 and 41 pages of information respectively. The Privacy Officer (PO) contacted both Veterans and requested…

Outcome: The information was incorrectly forwarded to the veterans by an ROI employee who was responsible for ensuring that the correct information was included in the shipping envelopes. The error and responsible user was verified by auditing the DSS ROI and…

Issue: The Privacy Officer (PO) received a phone call from a Veteran's daughter informing that her father received a packet of medical records that belong to Patient B. Release of Information (ROI) will send Patient B's medical records to the correct…

Outcome: Clerk was counseled.

Issue: Patient A received her medications via mail as well as 2 medications that belonged to Patient B. Also included in the bag were medication labels that contained Patient B's name, address and the name of the medications, dose, route, and…

Outcome: Pharmacy Supervisor has retrained/reeducated employee involved in this incident on importance of verification process.

Issue: A UPS employee reported that the packaging was ripped, and some of its contents was thrown away. The contents of the packaged contained the full names, full SSN, addresses, and bank account information. Update: 06/06/12:Even though this is not fault…

Outcome: The incident occurred at UPS- no corrective actions required by VA staff.

Issue: A Veteran patient reported that while walking through the facility, she came upon a stack of papers that was unattended. The paperwork was determined to be an inpatient list containing the full name, partial SSN, admission date, and ward location…

Outcome: The source of the document could not be verified. A review of the security cameras revealed that the location was not covered by the cameras. An OI&T search could not identify the originating printer location. Staff members have been reminded…

Issue: Medications, belonging to Veteran A, were mailed by Employee B to Veteran B. The information at risk included Veteran A's name, and medication information. Update: 05/29/12:Veteran A will receive a HIPAA notification letter.…

Outcome: The employee responsible is a repeat offender in making such errors and so her supervisor and the Chief of Pharmacy have referred her to human Resources (HR) to see if she can be transferred or removed.

Issue: Veteran requested a copy of her medical records and Employee A fulfilled her request but inadvertently included a copy of a Benefit Travel List containing the first and last name of 20 veterans with their full SSN's in her packet.…

Outcome: Employee has been counseled to review each and every piece of paper prior to providing copies of medical records to Veterans to verify accurate patient identification.

Issue: At approximately 2:30 PM on 05/07/12, a Veteran/Patient stopped by the Information Security office to report that he just left x-ray and saw Patient B's Personally Identifiable Information (PII) on a little console screen in the x-ray room. The Veteran…

Outcome: BioMed staff disconnected the offending displays so they do not light up and will no longer display patient information.

Issue: A nurse inadvertently mixed mailing instructions from the primary care provider. Patient A's information was mailed to Patient B after their walk-in visits on 05/03/12. The information included Patient A's full SSN and medication list. Update: 05/07/12:Patient A will be…

Outcome: The employee responsible and all staff have been re-educated.