VA Heart of Texas Health Care Network (VISN 17)

Issue: While Patient A was in the surgery holding area on 02/15/11 waiting for surgery, it was alleged that the Operating Rroom (OR) staff was discussing the reason another patient was having surgery and how the injury happened. This was overheard…

Outcome: All OR staff were re-educated.

Issue: Veteran/Employee complains that a Patient Advocate (PA) inappropriately accessed their record without the need to know and discussed with them medical information contained in the medical record. The reporter states that the visit with the PA was as an employee…

Outcome: The PO finds that the accessing of the medical record for this employee/Veteran was inappropriate for the stated purpose. PO requests that the Supervisor contact HR for the appropriate sanctions. Also requests that the employee retake VHA Privacy/HIPAA training. No…

Issue: Veteran A called stating that when he received his documents he requested from Release of Information (ROI), one of the notes had Veteran B's name, full SSN, and DOB in the body of the note. After researching this, it was…

Outcome: This was a copy and paste error done by a Social worker. Social Work service has been contacted and the individual has been re-educated. Also Health Information management has been made aware of the copy and paste issue and the…

Issue: A patient was admitted through the Emergency Department with the wrong wrist band. A wristband for a patient with the same last name was printed by mistake and placed on the patient. As soon as the patient got to his…

Outcome: Staff were re-educated on the proper placement of wristbands.…

Issue: An Inpatient Physical Therapy patient list was found on the 2nd floor hallway near the old Equal Employment Opportunity office. The list was found by VHA staff member and includes patients last name, last four and unit location. There is…

Outcome: Staff was re-educated.

Issue: Patient A was wearing Patient B's arm band. The arm bands contain full name and full SSN. The lab tech went to draw blood and noticed the mistake. The incorrect armband was removed by the nurse right away. Apparently the…

Outcome: Staff were re-educated on the proper placement of wristbands

Issue: An employee involved in a labor action requested a copy of the evidence file. The request was processed and released by a Human Resources (HR) staff member. A copy of the evidence file was provided and the requesting employee discovered…

Outcome: The employee has been re-educated on the importance of following the established guidelines for handling/processing this type of information. Referred to the HR Service Chief and Supervisor for the appropriate sanctions.

Issue: Two Veterans were given each other's information. The documents contained the Veterans' full name, full SSN and address. The mistake was noted a few minutes afterwards while the two were still at the clinic. Update: 032/19/12:Both Veteran will receive e…

Outcome: Credit monitoring to the Veterans involved (2). Employees were reminded to check and double check to ensure information is being provided to the person to whom the information pertains.…

Issue: Veteran A reported that two letters were sent to his home address. One letter was intended for Veteran A. The second letter was addressed to Veteran B. The letter contained Veteran B's full name, full address, last four digits of…

Outcome: . The supervisor retrained the employee on handling sensitive information and mail outs. The employee re took the privacy training given by the Alternate Privacy Officer and both the supervisor and the privacy officer educated the employee on proper handling…

Issue: During Police rounds, an unsecured document was found on a printer in the new Polytrauma Unit. The document was printed on 02/17/12 and was found on the morning of 02/19/12. The document contained the patient's name, full SSN, date of…

Outcome: staff educated on retrieving documents from printer