VA Heartland Network (VISN 15)

Issue: A VA employee health file was removed from Employee Health and subsequently located in the Eye Clinic on a desk. Update: 07/21/11:Employee A will receive a letter offering credit protection services.…

Outcome: Need for eliminating all possible opportunities for someone to accidentally pick-up an employee health folder off the desk in employee health was discussed. Re-design of the work area and other options are being explored and discussed with involved individuals. (gkg)…

Issue: An OI&T employee noticed documents on printer in the IT training room. Documents contained Full SSN, full Name, medication and Protected Health Information (PHI) of Veteran A. Document was printed on 6-3-11, training room is a high traffic area. Unable…

Outcome: Unable to determine responsible party for documents printed to public printer. PO stresses the importance of safeguarding documents in new employee orientation and attends staff meetings to reiterate importance of proper use and disposal.…

Issue: Employee found documents in locked conference room this am. Documents found were assumed to be notes protected USC 5705 (Quality Assurance) as part of quality improvement process. Progress note included PHI/PII of one Veteran. Room was locked overnight and it…

Outcome: Credit monitoring letter signed by Director mailed 7-11-11. Quality Assurance team has been provided additional education on use and disposal of documents with PHI…

Issue: Employee A sent internal Outlook email to a email group of 75 employees. In the email Employee A discussed health of Employee B. Update: 05/09/11:Employee B will receive a notification letter.…

Outcome: PO provided re-education to responsible party and I attended service line staff meeting to review privacy do's and donts. Notification letter mailed. Appropriate action taken by HR and service line. Notification letter scanned to VAidentity.…

Issue: The Health Administration Supervisor reported receiving a letter from Veteran A stating "lab results mailed to me by mistake". The Privacy Officer (PO) secured the document. The lab results ncluded Veteran B's full SSN, fulll name, medical information. Update: 07/28/11:Veteran…

Outcome: The Service Line Operations Manager will remind staff to double check documents prior to mailing. The PO provided training awareness to Operations staff.…

Issue: An employee working in the Release of Information (ROI) Section mismailed Veteran A's medical record documents to Veteran B. The documents contained Veteran A's name, full SSN and protected health information. Update: 04/18/11:Veteran A will receive a letter offering credit…

Outcome: Employee given verbal counseling and remedial training.

Issue: A employee temporarily assigned to Release of Information (ROI) Section mismailed Veteran A's medical record documents to non-VA attorney. The documents contained Veteran A's name, full SSN and protected health information. Update: 04/18/11:Veteran A will receive a letter offering credit…

Outcome: Employee has received verbal counseling and remedial training.

Issue: An employee temporarily assigned to Release of Information (ROI) Section mismailed Veteran A's medical record documents to the facility's VA Police. The documents contained Veteran A's name and full SSN. Update: 04/18/11:Veteran A will receive a letter offering credit protection…

Outcome: Employee has received verbal counseling and remedial training.

Issue: An employee's personal information contained in a Proficiency Report and Functional Statement was erroneously given to another employee. The information contained on this paperwork included the employee's full name, last four digits of the SSN, DOB, computation date, position title,…

Outcome: Employee responsible for mishandling of information was counseled by supervisor.

Issue: The facility pharmacy mailed Veteran A's medications to the wrong Veteran (Veteran B). Update: 04/12/11:Veteran A will be sent a notification letter.…

Outcome: Pharmacy reviewed the risks in assigning multuple duties to stamm. Verbal counseling and retraining in procedure provided to employee responsible. All staff were briefed of the incident.…