VA Heartland Network (VISN 15)

Issue: A VA employee gave the wrong paperwork to Veteran A following an appointment. It went unnoticed until later in the day. Veteran A received Veteran B's full name, full SSN, and lab results. Update: 10/21/11:Veteran B will be sent a…

Outcome: Information returned to VA. Responsible employee counseled by supervisor. Credit Protection letter provided. Recommend incident be closed.…

Issue: A Veteran alleges that his ex-girlfriend, who is a former employee at the facility, inappropriately obtained information from his VHA medical records. He stated that she knows medical information regarding his medical provider assignments and medication regimen that he has…

Outcome: VA Police talked with the ex-girlfriend on October 28, 2011, when they issued a stern warning to her that if she continued to utilize VA telephones to contact the Veteran, she would be considered in violation of the order of…

Issue: Veteran A reported that he received Veteran B's instruction paperwork included with the packet of information that he received with his procedure prep kit from the Pharmacy. The paperwork contained Veteran B's full name and address, along with instructions on…

Outcome: PO provided education to the staff. They were reminded to be more careful when matching instruction inserts with prescriptions.…

Issue: The History and Physical Progress note of an inpatient Veteran was found on top of an isolation cart on Medicine ward area. Unable to determine responsible party of failure to safeguard/disposal of Veteran PHI. Update: 09/28/11:Due to full SSN and…

Outcome: Unknown responsible party. PO provided training through Chief of Staff and Associated Chief of Staff for Education.…

Issue: Veteran's occult blood testing card was erroneously mailed to another Veteran, the card contained full SSN, full name and DOB. Update: 09/12/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: Responsible employee provided additional education on responsibilities of protecting Veterans information. Credit protection letter provided to affected Veteran.…

Issue: Veteran A received Veteran B's prescription from the prescription window. Veteran B's name and type of medication was disclosed. Veteran A was called once the error was discovered and Veteran A said that he will not return to Poplar Bluff…

Outcome: Education was provided with a double check system to be put in place.

Issue: Veteran A, who is a patient/employee at this facility, reported that on09/02/11, he received an appointment reminder letter which contained Veteran B's anticoagulation education note. Veteran A returned the mis-mailed documents to ththe Privacy Officer (PO) on 09/06/11. Update: 09/06/11:Veteran…

Outcome: Education has been provided to staff and process has been reviewed and revamped to lessen the likelihood of future incidents of this nature. Anti-coag education letters will no longer contain full SSN and full DOB. Staff will remove this portion…

Issue: DAV Commander received documents from Veteran A. Veteran A had requested and received copy of medical records. Veteran A discovered in addition to her own medical records, there were records belonging to Veteran B. Update: 08/30/11:Veteran B will be sent…

Outcome: PO provided face-to-face re-education to employee. CM letter mailed 9-16-11.…

Issue: A VA employee reported that another employee disclosed personal patient information, including the diagnosis, about another co-worker. Update: 08/30/11:The co-worker will receive a letter of notification.…

Outcome: Responsible individual counseled by supervisor and provided additional training on responsibilities of protecting Veterans' and employees' PII and PHI. Notification letter sent to affected individual.…

Issue: Employee A in the voluntary leave donation program had information of the acuity of her illness disclosed in an email sent by service line employee seeking leave donations. The email was sent to employees of the service line, not external…

Outcome: PO provided re-education to employee responsible. Appropriate action taken by HR and service line. Notification letter mailed on 9-1-11.…