VA Heart of Texas Health Care Network (VISN 17)

Issue: Veteran A was handed fee authorization by fee clerk. When Veteran A reviewed the information at home, he realized he had also received Veteran B's fee authorization. Veteran A called the clinic and notified an employee of the occurrence. The…

Outcome: Employee supervisor notified and has instructed employee to retake Privacy and Information Security training by close of business Friday, December 16, 2011. Credit monitoring letter sent to Veteran B.…

Issue: A consult for home oxygen was faxed to a lock and key company instead of the Home Oxygen medical supply company. The lock and key company immediately contacted the Veteran and his family (son has Power of Attorney(POA)), and mailed…

Outcome: Staff re-educated on faxing information - verify number and confirm received.

Issue: An employee contacted the Privacy Officer (PO) to report that her father, a patient in a local nursing home, had received medical information belonging to Veteran B in the mail. The employee was contacted by the nursing facility and after…

Outcome: The ROI employee was neglegent by not reprinting a new disclosure letter. Findings forwarded to Service Chief with instructions to contact HR for corrective action.

Issue: The Privacy Officer was contacted by an employee who was reporting that Veteran A had returned information belonging to Veteran B. The information was received and attached to information pertaining to Veteran A. The form was a benefits form that…

Outcome: The source of the disclosure could not be identified. Credit letter forwarded to the Veteran.

Issue: Patient A received medication that was for Patient B. Patient A returned the medication back to facility. The medication label consisted of Patient B's last name, first name and type of medication. Update: 11/18/11:Patient B will receive a letter of…

Outcome: Chief of this service has spoken to Supervisor in charge where incident has occurred. Supervisor will be conducting a mandatory training/in-service on the importance of Patient Identification Policy and verification within 2 weeks to their employees.

Issue: PO received an email message from the Patient Advocate who was reporting that they a met with a veteran who was reporting that he had been notified by a staff member and was informed that an employee had contacted the…

Outcome: The Privacy Officer has determined that this was an inappropriate access of the medical record. The PO refers this finding and recommends that the Service Chief contact HR to discuss the appropriate sanctions.

Issue: Veteran Employee A requested a sensitive record audit from 8/1/07 to 5/8/009. Report revealed that employees B, C, D and E had accessed employee A's record. Update: 11/01/11:Employee/Veteran A will be sent a letter offering credit protection services due to…

Outcome: Education on accessing of employee/Veteran records will be provided to all employees involved NLT 11-11-11. Credit monitoring letter has been sent to Veteran/employee.…

Issue: An appointment letter for Patient B was in same envelope mailed to Patient A. Update: 10/28/11:Patient B will be sent a notification letter due to full name and PHI being exposed.…

Outcome: Staff was re-educated.

Issue: The Edgewater Nursing Home staff brought Veteran A to the facility for an appointment. During the course of transporting the Veteran, they dropped documents containing the Veteran's name, full SSN and diagnosis. The Privacy Officer (PO) called the Nursing Home…

Outcome: Staff has been re-educated.

Issue: An employee printed out Veteran A's active medication list. When the employee went to retrieve the printed medication list, the employee also handed the Veteran two other medication lists and discharge summaries of 2 other Veterans by mistake along with…

Outcome: Supervisor has met with staff for reeducation/retraining of appropriate handling of all VA sensitive information. Measures have been implemented to have page separators in the printers located at this facility to prevent further disclosures or mix-up of patient data. Notification…