VA Heartland Network (VISN 15)

Issue: Veteran A presented hospital discharge paperwork, to VA facility, that belonged to Veteran B. Update: 09/12/12:Due to full SSN and medical information being exposed, Veteran B will receive a letter offering credit protection services…

Outcome: Counseling of employee. Procedures reviewed with all staff.…

Issue: A Veteran received a CD and paper records which contained the personally identifiable information (PII) and/or protected health information (PHI) of another Veteran. The records were mailed to Veteran A's home. The records were for Veteran B. Veteran A returned…

Outcome: CM letters mailed. PO provided education to employee. HR and service has completed appropriate disciplinary action.…

Issue: A packet full of Veteran's information was left on a wheel chair near a patient waiting area. Update: 08/20/12:Due to full SSN and medical informationi being exposed, Veteran A will be sent a letter offering credit protection services.…

Outcome: Veteran contacted and packet returned. Credit protection letter sent to affected Veteran. Recommend item be closed.…

Issue: A VA employee at the Parsons CBOC accessed a medical record of a Veteran with the same last name. The Information Security Officer (ISO) inquired with the VA employee (to include supervisor) if they were related. Access to the medical…

Outcome: Responsible employee counseled by ISO and supervisor. Written letter of counseling given to employee. Notification letter sent to affected Veteran.…

Issue: Blue Clinic: On 08/09/2012, received phone call from a congressional office that Veteran A had reported to them that he had received Veteran B's medical information when leaving his medical appointment on 08/08/2012. Veteran A is concerned that his medical…

Outcome: This incident has been thoroughly investigated. Measures have already been taken to lessen the likelihood of future incidents of this nature. Education has been provided to staff. They have been reminded to double-check medication reconciliation forms to ensure they are…

Issue: Veteran A came in to Release of Information (ROI) and requested a copy of his x-rays to be on CD. The CD was burned and apparently the Release of Information clerk did not look at the CD careful enough and…

Outcome: Education and double check safeguards are put in place so this type of incident does not happen again.

Issue: Veteran A reported that he received a 10-10 form intended for Veteran B. The form was reported to contain Veteran B's full name, address, and SSN. It is unclear at this time if the form contained financial information. Veteran A…

Outcome: Education was provided to the staff member who made the error. Staff members in the work area were reminded of the importance of double-checking information being mailed to ensure it is being mailed to the correct Veteran.…

Issue: A VA Supervisor reported that a Veteran received a means test list containing 9 Veterans' information from a ward clerk. The Veteran reported the incident and also turned over the list to the Administrative Officer of the Day who in…

Outcome: The importance of taking time to ensure the confidentiality of Veterans' personally identifiable information is safeguarded was reinforced to staff in the clinic area of concern-double-checking information prior to giving it back to an individual is a check & balance…

Issue: A Veteran turned in a hard copy medical record found in restroom to a VAMC Supervisor. Update: 07/03/12:A VA eEmployee admitted leaving the medical record in restroom and wanted to self-report. Therefore Veteran A will receive a letter offering credit…

Outcome: Employee was given a verbal couseling by Acting ROI/File Room Supervisor and Privacy Officer.

Issue: A VISN employee reported to the Privacy Officer that during site inspection of VISN 15 Kansas City VAMC, the employee forgot to redact the name and diagnosis on the exit briefing report. The employee name and diagnosis were included in…

Outcome: The mishandling (lack of safeguard) by an employee who self-reported incident served as a good reminder/training opportunity. As the inappropriate disclosure of one employee/veterans PHI on an internal report was caught at the time the report was presented distributed to…