VA Heartland Network (VISN 15)

Issue: An EKG machine malfunctioned in the middle of an EKG and instead of removing the half way printed EKG, the nursing staff left the EKG on the machine in the hallway unsecured. Unsure when the EKG was done at this…

Outcome: On February 19, 2013, a brief in-service was provided to the nursing staff involved with the EKG issue, consisting of discussion of the incident and the medical center policy. A reminder of the policy was sent to all staff.

Issue: Veteran A requested a Sensitive Patient Access Report (SPAR) to determine who had accessed her medical records since discharge from the RRTP program. Veteran A stated that she was concerned about one particular employee, as the employee had been sending…

Outcome: The following measures have already been taken to lessen the likelihood of future incidents of this nature: 1) To further protect the medical records of RRTP participants, the records of all participants will now be marked sensitive. 2) Education has…

Issue: A nurse allegedly verbalized a patient medical progress note in a public area. The nurse read notes of a Veteran involved in a sentinel event. A witnesses reported hearing the nurse read progress note. Update: 02/11/13:The Veteran will recieve a…

Outcome: HR has pending disciplinary action.

Issue: A VA employee had another VA employee access a family member's medical record to gain information on the family member's medical condition. The family member affected had said that he definitely did not want any of his family to know…

Outcome: Responsible employee reprimanded by supervisor. Notification letter sent to affected Veteran.…

Issue: Employee found progress-style note for one inpatient Veteran in vending/breakroom. PO is contacting inpatient ward to follow up on where or who had this handwritten note. Update: 01/23/13:One Veteran will receive a notification letter.…

Outcome: PO provides education to employees of the department.

Issue: A Veteran received his appointment letter. Within the envelope was also lab results of five different Veterans. When this discrepancy was discovered by recipient, he returned the mismailed documents to the VA. Update: 01/10/13:Five Veterans will be sent a HIPAA…

Outcome: Responsible employee re-educated on responsibility of ensuring strict security when mailing out letters. Notification letters sent to affected Veterans. Recommend incident be closed.…

Issue: Veteran A's prescription information was erroneously placed in Veteran B's prescription bag. Upon discovery by Veteran B, the information was returned to the medical center Update: 12/13/12:Veteran A will be sent a letter of notification.…

Outcome: Responsible employee counseled by Service Chief. Notification letter provided to affected Veteran this date.…

Issue: A Community Based Outpatient Clinic (CBOC) employee reported that she accidentally faxed a Veteran's non-VA records to an incorrect fax number after transposing the numbers. The documents contained the Veteran's full name and DOB, and other medical information. The documents…

Outcome: Employee was reminded to use caution when entering fax numbers and to double-check to ensure correct number has been entered.

Issue: Veteran A reported receiving Veteran Bs appointment letter Veteran A promptly notified his social worker who immediately notified the Privacy Officer (PO) . Veteran A was to bring the letter with the envelope to his next appointment since it was…

Outcome: Re-education provided to individual processing appointment letters; supervisor notified and a quality control corrective action plan implemented by the responsible office, to mitigate this type of miss mailing error. 1-29-2013 Notification Ltr sent & redacted copy uploaded…

Issue: Veteran alleges a HIPAA violation since the specific topic is not something he would normally talk about with a friend of his or anyone with the exception of his wife. Veteran states he has been increasingly more pprehensive; hesitant in…

Outcome: From the result of the AIB, the alleged individual's conduct was at issue and substantiated as inappropriate; however, as stated under the activity tab: a privacy breach could not be confirmed. A suspension as well as a reassignment of duties…