VA Heartland Network (VISN 15)

Issue: Veteran A reported that he had received Veteran B's medical records. An initial investigation revealed that Veteran A had initiated a release of information (ROI) request on August 12, 2011, for his most recent audiology report. On August 18, 2011,…

Outcome: Investigation revealed that the issue was a result of a software issue. OI&T staff are working to resolve the issue. Staff were reminded to double-check cover letter and responsive documents to lessen the likelihood of future incidents.…

Issue: Veteran's medical information was erroneously mailed to another Veteran. Update: 08/18/11:One Veteran will be sent a letter offering credit protection services.…

Outcome: Responsible individual counseled by supervisor and provided additional training on awareness and responsibilities when processing outgoing mail. Credit protection letter sent to affected Veteran.…

Issue: Employee A went into Employee B's CPRS record reportedly because she was curious to find out if Employee B was her husband's ex-wife. The supervisor has been apprised of this situation and this is being turned over to management for…

Outcome: These records are marked as sensitive. Monitoring of sensitive record access logs will continue to make sure that this does not reoccur. Management is processing administrative action against the employee.…

Issue: An employee left paper documents in a government vehicle. The documents were discovered when the vehicle was returned. The documents were of various types:A Home Based Primary Care (HBPC) Medication Reconciliation report for 2 Veterans. Report contains full name, and…

Outcome: Letters signed and mailed 9-1-11. Appropriate action taken by HR and service line. PO provided re-education on safeguarding documents with PHI.…

Issue: The Patient Advocate sent an email advising the Privacy Officer (PO) of an incident. Veteran A came to Patient Advocate on 08/15/11 and reported receiving an appointment cancellation letter that had a list of other patient names attached to it.…

Outcome: PO assured responsible clinic clerk is current with VHA Privacy Policy Web Based Training. Additionally employee reminded of need to be careful when mailing PII/PHI. Additional sanctions possible. (gkg)…

Issue: A Veteran reported that his behavioral health provider had submitted a physician's statement to his employer without proper authorization. The initial investigation reveals that the patient had an appointment on 07/27/11, during which it was determined that the Veteran should…

Outcome: Training and education regarding release of information procedures were provided to the staff member who completed the forms. Employee was reminded that a release must be in place prior to any information being released, unless in an emergency situation.…

Issue: A VA employee accessed her sons enrollment/eligibility information in VistA and shared with the VISN Enrollment/Eligibility Coordinator to ask the status. The employee had no authority or business reason to access her sons application. Employee had been previously cautioned against…

Outcome: Contacted employee Supervisor and employee regarding inappropriate access. Requested sensitive record flag be placed on Veteran record.…

Issue: A room utilized by a Dialysis Contractor was left propped open. An IV bag was found with Patient A's full name, room number, partial SSN. The IV bag was found on 08/08/11, the IV solution was dated 07/28/11. The bag…

Outcome: Staff was provided with additional training to safeguard Veteran information. Work order has been entered to change code on door.. Redacted letter has been attached.…

Issue: Veteran A telephoned Truman VAMC to report that there was other Veterans' protected health information in his USPS bubble mailer . The Veteran explained his concern for the receipt of this information, and that he would be "glad to return…

Outcome: Appropriate action taken by HR and service line. Credit monitoring letters mailed. Redacted letter attached.…

Issue: A VA employee who was working temporarily in the Release of Information Section provided medical documents to the wrong Veteran. The information contained medical information and demographics to include full SSN. Update: 07/20/11:Veteran B will be sent a letter offering…

Outcome: Documents retrieved by PO. Employee received Counseling Memorandum. Reeducation by PO.…