VA Heartland Network (VISN 15)

Issue: A Release of Information Technician inadvertently included medical documents of Veteran A in a mailing to Veteran B. Veteran B reported error to ROI Supervisor. Update: 04/08/11:Veteran A will receive a letter offering credit protection services.…

Outcome: Employee given verbal reprimand. Action mitigated by high volume of PHI/PII mailed by Section.…

Issue: A complainant reports that his supervisor disclosed protected health information (PHI) to a Union official without his consent. Update: 04/13/11:The supervisor acknowledged her use of employee's name and medical condition. The supervisor went to the Union official to get their…

Outcome: Employee received appropriate HR disciplinary action, notification letter mailed on 4-22-2011.…

Issue: Veteran A received two medications that were meant for Veteran B from one of our outpatient pharmacies. Two patients medications got put in one sack and dispensed to a single patient. The error was caught quickly and the patient was…

Outcome: No SSN. Medication returned with paperwork in entirety to facility. Re-iterated to Pharmacy staff the importance of double checking identification and all movements of medications; staff understood.…

Issue: Veteran A picked up his prescription at the pharmacy window on March 25, 2011. He was given the right bottle of medication, however, his bag contained the paper work information for Veteran B. He was instructed by Pharmacy to destroy…

Outcome: New Process set up in which a double check is used before medication or information is given to a patient at the pharmacy window.

Issue: Medication was mailed to the wrong Veteran. The Veteran returned the medication after reading another Veteran's name on label. Update: 03/24/11:Veteran B will be sent a notification letter.…

Outcome: Pharmacy addressed package correctly. USPS mis-delivered.…

Issue: Medical progress note found on Environmental of Care (EOC) rounds by the privacy officer (PO) the note contained full name, DOB and full SSN of one Veteran. The document was found behind a computer work station. The note was printed…

Outcome: Credit Monitoring letter mailed to Veteran on 3-24-11. PO is providing awareness and education to all service lines and sections at monthly staff meetings..…

Issue: A Veteran reports being involved in a court case with ex-wife. He alleges ex-wife provided (verbal) information to her attorney that she could know only as a result of having accessed his medical records without his authorization. He reports having…

Outcome: A letter of proposed removal has subsequently been given to VA employee (vet's ex-wife). Awaiting Final outcome of this proposed action.

Issue: A staff member accessed the medical record of a person applying for a VA job. The VA staff member apparently checked the record in an attempt to determine if he would be a poor candidate and told the selection team…

Outcome: The following actions have been taken: 1. Interview panel comprised of new members, re-interviewed all applicants. 2. Employee in question has retaken privacy and information security training. 3. Privacy and information security training was given to the entire department in…

Issue: A schedule of Surgical procedures was discovered in stairwell outside Surgical area. The stairwell primarily used by employees. The paperwork contained the PII of 14 patients Update: 03/07/11:The Privacy Officer (PO) is unable to determine exactly how long the information…

Outcome: All employees in ADS trained on their responsibilities of protecting sensitive information. Notification letters sent out this date.…

Issue: Mismailing happened with veteran a receiving both his appointment letter and veteran b appointment letter. Update: 02/24/11:Due to appointment information being disclosed, Veteran B will receive a notification letter.…

Outcome: Education was provided with double check system.