VA Heartland Network (VISN 15)

Issue: A VA Employee provided copy of authorization to release information from Veteran A to Veteran B. Veteran B telephoned the coordinator to report error. The Privacy Officer (PO) has requested Veteran to return document. Scanned image of document will be…

Outcome: PO has provided education to employee, he is aware of this type of breach and the explains it was human error. HR and service will provide disciplinary actions as deemed appropriate.…

Issue: Veteran A received a packet for Home Improvements and Structural Alterations (HISA) from the prosthetic office. He came to the Community Based Outpatient Clinic (CBOC) to have help with filling out the papers and on opening the packet. It was…

Outcome: Per supervisor: "I educated all staff in Prosthetics to ensure they review all document prior to mailing to the Veterans and the staff member who is responsible is completing the Privacy/ HIPPA module in TMS."…

Issue: The Scanning Section scanned non-VA medical documents into wrong Veteran's (Veteran A) record. Veteran B (same first and last names as Veteran A) received Veteran A's records. Update: 03/27/12:Veteran A will be sent a letter offering credit protection services. Veteran…

Outcome: Responsible employee identified. Verbal counseling. Root Cause Analysis directed by facility Director.…

Issue: Information was found loose in the mail room at Warrendale, PA postal facility. Once discovered, the postal facility returned package to Wesley Medical Center Wichita KS because they identified paperwork included that contained that medical center's address. Once discovered, Wesley…

Outcome: Credit Monitoring letter provided to Veteran. All available documentation retrieved from USPS. No fault of the VA but due to full SSN being exposed the VA will provide a letter offering credit protection services to the Veteran.…

Issue: Nurse facilitator relates that on 02/23/12, the interdisciplinary team met for rounds on the acute care floor. The team consists of hospitalists, the nurse facilitator and social worker. The patient in question was discussed and the hospitalist felt his condition…

Outcome: Employee was educated as well provided training in releasing of information by supervisor.

Issue: Community Living Center (CLC) Resident A was discharged to his home on 02/17/12 and was accidentally given a medication bottle labeled with CLC Resident B's name. Pharmacy sent a staff member to Resident A's home to retrieve the medication. The…

Outcome: Staff have been reminded, when discharging patients, to double-check items being released to ensure they are being released to the correct patient.

Issue: A Veteran was brought in to the Emergency Room by Emergency Medical Services (EMS) personnel. His personal belongings included a manila envelope with his VA ID card and military ID card. The manila envelope was lost and a thorough search…

Outcome: Veteran issued new VA I.D. card. Credit protection letter sent this date. Recommend item be closed.…

Issue: On 02/10/12, Veteran A reported that he had received Veteran B's medication to the Poplar Bluff VAMC via a telephone call. The Privacy Officer (PO) at Poplar Bluff notified this writer of this incident, as it occurred secondary to a…

Outcome: Education was provided to clerk, reminding to verify SSN prior to accessing or making edits to demographic information. Request has been made for records to be flagged to alert staff to identical names.…

Issue: Upon discharge, Veteran A received the discharge paperwork of Veteran B. Veteran A did not know he received the wrong paperwork until he got home. The paperwork included Veteran B's name, full SSN and medication information. Update: 02/02/12:Veteran B will…

Outcome: Work area employees briefed on responsibility of ensuring proper steps are taken when mailing sensitive information. Credit monitoring letter provided to Veteran.…

Issue: Veteran A received appointment letter from the Primary Care Clinic and found appointment letter of Veteran B in the same envelope. The administrative clerk from the service advised Veteran A to discard the letter. The Privacy Officer (PO) is unable…

Outcome: Veteran mailed notification letter. PO provided education to service. irresponsible party is unknown.…