VA Heartland Network (VISN 15)

Issue: NOK request records of deceased veterans. The NOK did not provide an address so the address that was in Vista was used. This address has since changed and it was not known at the time the records were sent with…

Outcome: ROIs department was educated on the need to verify address.

Issue: Patient requested copy of medical record. Paperwork packaged and mailed by VA. Upon receipt at home, package was discovered to be less than secure. Patient received 1002 documents. Upon investigation, there should have been 1005 documents. Update: 02/15/11:The medical record…

Outcome: Credit protection sent to Veteran this date. Recommend item be closed.…

Issue: Veteran A received an appointment letter in the mail, which contained Veteran B's and Veteran C's full name, full SSN, and home telephone numbers. The investigation revealed that the letter had been printed on "recycled" paper, which was thought to…

Outcome: The following corrective actions have been taken: 1. Service Chief sent message to all staff under his direction, instructing them to cease recycling paper. 2. Printer settings were changed to prevent "wasting" of paper (two blank papers of paper printed…

Issue: Progress Note for Veteran A discovered in paper copy of Veteran B's records. Progress note contained 7332 information. Document returned to VA by Veteran B. Note had been placed in Veteran B's record in September, 2006. Note was discovered by…

Outcome: Responsible employee counseled by Supervisor, re-educated by Privacy Officer.

Issue: Veteran A believes that an unauthorized disclosure of his information (which he feels was inaccurate in addition to being disclosed without his authorization) resulted in his social security benefits being suspended. Documentation in the medical record does not support Veteran…

Outcome: The individual alleged responsible for this breach left VA employment sometime ago. "prior" to this incident being reported. Supervisor of dept. however has reiterated to staff in department, the need for patient privacy and the fact that it everyone's responsibility.…

Issue: Transitional Living Center (TLC) Activity Sheet was discovered in the TLC activity room by a VA employee. The paperwork was immediately reported to the Privacy Office and the paperwork was given to the TLC supervisor. The supervisor had the paperwork…

Outcome: Nursing Manager briefed all employees of their responsibilities for protecting sensitive information. Credit protection letters sent out this date. Recommend incident be closed.…

Issue: Pharmacy employee mis-mailed prescriptions to the wrong Veterans. Veteran A received Veteran B's prescription and vice versa. Veteran A called the pharmacy to report receiving wrong RX's. Veteran B was called by pharmacy and confirmed he had received the wrong…

Outcome: Appropriate management action has been taken. PO performed re-education to staff.…

Issue: During new provider orientation, medical coder inadvertently presented information on a Veteran and did not utilize "Test Patient" account. The encounter form presented included name, DOB and full SSN. The document was shown on screen, no physical document was distributed.…

Outcome: Appropriate management action has been taken. PO is scheduled to provide additional education at next staff meeting.…

Issue: Dr. provided Veteran A with consult note for Veteran B. Veteran B's wife telephoned clinic to inform of error. Veteran B's wife concerned if their PHI/PII was given to Veteran A, it was not given to Veteran A. Doctor acknowleged…

Outcome: Education will be proviided to staff. Credit monitoring letter has been mailed to Veteran.…

Issue: Patient A received Patient B's medication. Both patients have the same last name. Their medications were not the same, however both were controlled substances. Update: 01/03/11:As soon as Patient A was able to do so, he called into Pharmacy and…

Outcome: Notification letter was sent.