VA Heartland Network (VISN 15)

Issue: A veteran received their pre-appointment letter stapled to another veterans pre-appointment letter (both appointments at the same VAMC). The Veteran who received the wrong information returned the original documents. Information disclosed was full name, partial SSN, medical appointment information, and…

Outcome: The manager in the department where error occurred has been notified and they have implemented a process of double-checking (quality assurance) of documents with the names on the documents with 2 individual staff personnel prior to appnt information being mailed.…

Issue: Veteran A received claimant/demographic information of Veteran on B the DC (discharge) instructions after surgery. ROI (Release of Information) Department received a PACU packet from surgery with the last page being the Post Procedure Patient Teaching Surgery form (basically the…

Outcome: Action Plan: The manager in the department where error occurred has been notified and they have implemented a process of double-checking (quality assurance) of documents with the names on the documents with 2 individual staff . In addition, privacy &…

Issue: Veteran A's Audiology Compensation and Pension (C&P) report was mismailed to Veteran B. The document was included with Veteran B's medical records. Both Veterans had Release Of Information (ROI) requests processed on the same date. The mismailed documents were returned…

Outcome: The printer has been repaired. Education has been provided to staff, reminding them to double-check information to lessen the likelihood of future incidents. Credit monitoring letter was mailed to Veteran A on 12/02/2011.…

Issue: A note with a Veteran full name and full SSN was found on floor of public hallway. The public traffic in this hallway is light. Update: 11/23/11:Veteran A will be sent a letter offering credit protection services.…

Outcome: Reponsible party is unknown.. Credit protection letter mailed 11-30-11…

Issue: Veteran A received Veteran B's anticoagulation education note enclosed with his appointment letter. The education note contained Veteran B's full name, lab results of his INR and warfarin dosage information. The letter did not contain any other identifiers. Update: 11/21/11:Veteran…

Outcome: Education was provided to involved staff. They were reminded of the importance of ensuring the cover letters and the anticoag notes belong to the same Veteran.…

Issue: The Information Security Officer (ISO) received a call from the VA Police and stated the VA photographer lost a memory card. The ISO called the photographer. The photographer stated he picked up the camera memory card from a caregiver around…

Outcome: Actions taken: 1. Images on camera after upload (& quality checks) are not saved, but the memory card or (SD) scan disk is formatted whereby any images/information previously is no longer identifiable.2. If by COB (close of business) or near…

Issue: Veteran A received lab results of Veteran B in mailed correspondence. Veteran A returned documents to VA Privacy Officer. Update: 11/08/11:Veteran B will be sent a notification letter.…

Outcome: HIPAA notification letter mailed on 11-18-11. PO provided re-education to staff.…

Issue: Event Location: CLC The ACN of Extended Care reported concerns of a possible privacy violation. Her concerns were based on the fact that a Union Representative had presented a copy of a CLC resident's progress note to the Chief of…

Outcome: Per Labor Relations Representative, education was provided to the Union Representative and the employee who shared the patient's information. They were instructed on the procedures for requesting patient information for Union purposes.…

Issue: Veteran A received the appointment letter of Veteran B along with his/her own appointment letter. Update: 10/27/11:Veteran B will be sent a notification letter.11/10/11:The Privacy Officer (PO) advised IRT of an error made in sending the credit protection letter for…

Outcome: Credit protection letter mailed to Veteran on 11-7-11. Staff has been provided with reminder to check all correspondence prior to mailing.…

Issue: Veteran A received copy of Veteran B's medical record along with his copy of his own medical information. Update: 10/27/11:Veteran B will be sent a letter offering credit protection services due to full name and full SSN being disclosed.…

Outcome: Credit monitoring letter mailed to Veteran. Education and changes to procedures have been implemented.…